Chiles v. Salazar

P R E L I M I N A R Y P R I N T
Volume 607 U. S. Part 2
Pages 627–692
OFFICIAL REPORTS
OF
T H E S U P R E M E C O U R T
March 31, 2026
REBECCA A. WOMELDORF
reporter of decisions
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the bound volume is published. Users are requested to notify the Reporter
of Decisions, Supreme Court of the United States, Washington, D. C. 20543,
pio@supremecourt.gov, of any typographical or other formal errors.

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CHILES v. SALAZAR, EXECUTIVE DIRECTOR OF
THE
COLORADO DEPARTMENT OF REGULATORY
AGENCIES, et al.
certiorari to the united states court of appeals for
the tenth circuit
No. 24–539. Argued October 7, 2025—Decided March 31, 2026
Kaley Chiles holds a master's degree in clinical mental health and a state
counseling license in Colorado. Ms. Chiles does not begin counseling
with any predetermined goals; instead, she sits down with clients, dis-
cusses their goals, and then formulates methods of counseling that will
most beneft them, seeking throughout to respect her clients' fundamen-
tal right of self-determination. On matters of sexuality and gender,
Ms. Chiles's clients, including young people, often have different goals:
Some are content with their sexual orientation and gender identity and
want help with social issues or family relationships, while others hope
to reduce or eliminate unwanted sexual attractions, change sexual be-
haviors, or grow in the experience of harmony with their bodies. With
all those clients, Ms. Chiles seeks to help them reach their stated objec-
tives. And she employs only talk therapy.
In 2019, Colorado adopted a law prohibiting licensed counselors from
engaging in “conversion therapy” with minors, Colo. Rev. Stat. § 12–
245–224(1)(t)(V), defning the term to include “any practice or treatment
. . . that attempts . . . to change an individual's sexual orientation or
gender identity,” as well as any “effor[t] to change behaviors or gender
expressions or to eliminate or reduce sexual or romantic attractions to-
ward individuals of the same sex,” § 12–245–202(3.5)(a). Yet the law
explicitly allows counselors to provide “[a]cceptance, support, and un-
derstanding for . . . identity exploration and development,” § 12–245–
202(3.5)(b)(I), and to assist persons “undergoing gender transition,”
§ 12–245–202(3.5)(b)(II). Ms. Chiles fled suit in federal court seeking
a preliminary injunction, raising a First Amendment challenge to the
law as it applies to her talk therapy.
Both the district court and the Tenth Circuit determined that Ms.
Ch i les had Ar ticle III st andi ng to pursue her as-applied pre-
enforcement challenge. On the merits, however, both courts denied Ms.
Chiles's request for a preliminary injunction, reasoning that Colorado's
law is best understood as regulating professional conduct and that it regu-
lates speech only incidentally, thus triggering no more than rational-
basis review under the First Amendment. This Court granted certio-

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628 CHILES
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rari to resolve a circuit confict over how the First Amendment interacts
w
ith laws like Colorado's when those laws are applied to talk therapy.
Held: Colorado's law banning conversion therapy, as applied to Ms. Chiles's
talk therapy, regulates speech based on viewpoint, and the lower courts
erred by failing to apply suffciently rigorous First Amendment scrutiny.
Pp. 639–655.
(a) The First Amendment protects the inalienable right of every indi-
vidual to decide for himself “how best to speak,” Riley v. National Fed-
eration of Blind of N. C., Inc., 487 U. S. 781, 791, and laws regulating
speech based on its subject matter or “communicative content” are “pre-
sumptively unconstitutional,” triggering “strict scrutiny” that requires
the government to prove its restriction is “narrowly tailored to serve
compelling state interests,” Reed v. Town of Gilbert, 576 U. S. 155, 163.
“Viewpoint discrimination” represents an even more “egregious form”
of content regulation from which governments must nearly always “ab-
stain.” Rosenberger v. Rector and Visitors of Univ. of Va., 515 U. S.
819, 829.
The Court has recognized only a “few historic and traditional catego-
ries of expression”—such as fraud, defamation, and “fghting words”—
where content-based restrictions do not automatically trigger strict
scrutiny. United States v. Alvarez, 567 U. S. 709, 717. These catego-
ries are narrowly drawn and share a long and well-recognized histori-
cal pedigree.
A law regulating the content of speech cannot avoid searching First
Amendment review just because it mostly regulates non-expressive con-
duct. What matters is whether, in fact, the law regulates speech in the
case at hand, as illustrated by Cohen v. California, 403 U. S. 15, and
Holder v. Humanitarian Law Project, 561 U. S. 1. And the First
Amendment's protections extend to licensed professionals much as they
do everyone else. National Institute of Family and Life Advocates v.
Becerra, 585 U. S. 755, 766–767. Pp. 640–643.
(b) As applied to Ms. Chiles, Colorado's law regulates the content of
her speech and goes further to prescribe what views she may and may
not express, discriminating on the basis of viewpoint. The law permits
her to express acceptance and support for clients exploring their iden-
tity or undergoing gender transition, § 12–245–202(3.5)(b), but forbids
her from saying anything that attempts to change a client's “sexual ori-
entation or gender identity,” including efforts to change “behaviors,”
“gender expressions,” or “romantic attraction[s],” § 12–245–202(3.5)(a).
Her speech does not become “conduct” just because a government says
so or because it may be described as a “treatment” or “therapeutic mod-
ality.” The First Amendment is no word game, and “the exercise of

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Syllabus
constitutional rights” cannot be circumscribed “by mere labels.”
NA
ACP v. Button, 371 U. S. 415, 429.
The fact that the State's viewpoint regulation falls only on licensed
health care professionals does not change the equation. The First
Amendment protects the right of all to speak their minds, and NIFLA
expressly rejected the notion that professional speech is subject to “ `di-
minished constitutional protection.' ” 585 U. S., at 767. History is lit-
tered with examples of governments that have sought to manipulate
professional speech “to increase state power,” “suppress minorities,”
and censor “ `unpopular ideas.' ” Id., at 771.
Colorado's law does not implicate any recognized exception to the
Court's usual First Amendment rules. It does not require disclosure
of “factual, noncontroversial information in . . . `commercial speech,' ”
id., at 768, and as applied to Ms. Chiles, it does not regulate conduct in
a way that only “incidentally burden[s] speech,” id., at 769. All she
does is speak, and speech is all Colorado seeks to regulate.
Colorado's argument that the law regulates speech only incidentally
fails because the Court's speech-incident-to-conduct doctri ne asks
whether the law restricts speech only because it is integrally related to
unlawful conduct, or whether the law restricts expressive conduct only
for reasons unrelated to its content. Colorado's law does neither: Ms.
Chiles's speech does not bear a close causal connection to any separately
unlawful conduct, and the State's law trains directly on the content of
her speech, permitting some viewpoints but not others. Pp. 643–650.
(c) Colorado cannot establish that applying its law to Ms. Chiles falls
within a long tradition of permissible content regulation.
Colorado's arguments proceed at far too high a level of generality,
asking the Court to recognize a broad “ `First Amendment Free Zone' ”
for speech the State considers “substandard care.” United States v.
Stevens, 559 U. S. 460, 469. The Court's precedents foreclose aggregat-
ing discrete traditions of content-based regulations to sustain some new
and broader category of lesser-protected speech.
Even taking each of the traditions Colorado invokes on its own terms,
none supports the State's position. Colorado's suggestion that the stat-
ute represents a traditional law licensing of medicine fails because the
State has not presented persuasive evidence of a historic tradition—
the frst state “counselor-licensure bill” was adopted only in 1976—and
because licensing laws have traditionally addressed qualifcations, not
dictated a professional's point of view. Colorado's analogy to informed-
consent laws fails because such laws regulate speech only incident to
separate physical conduct and usually require disclosure of only factual
and uncontroversial information, whereas Colorado's law as applied to
Ms. Chiles seeks to silence a viewpoint she wishes to express. Finally,

630 CHILES
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Colorado's invocation of traditional tort claims for malpractice fails be-
cause
malpractice actions require exacting proof of injury caused by
breach of duty, “provid[ing] breathing room for protected speech,” Illi-
nois ex rel. Madigan v. Telemarketing Associates, Inc., 538 U. S. 600,
620, whereas Colorado's law threatens fnes, probation, and loss of li-
cense simply for expressing a particular view, and does not allow clients
to consent to practices that depart from the prevailing standard of care.
Pp. 650–655.
(d) The First Amendment stands as a bulwark against any effort to
prescribe an orthodoxy of views, refecting a belief that each American
enjoys an inalienable right to speak his mind and a faith in the free
marketplace of ideas as the best means for fnding truth. Laws like
Colorado's, which suppress speech based on viewpoint, represent an
egregious assault on both commitments. P. 655.
116 F. 4th 1178, reversed and remanded.
Gorsuch, J., delivered the opinion of the Court, in which Roberts,
C. J., and Thomas, Alito, Sotomayor, Kagan, Kavanaugh, and Bar-
rett, JJ., joined. Kagan, J., fled a concurring opinion, in which Soto-
mayor, J., joined, post, p. 655. Jackson, J., fled a dissenting opinion, post,
p. 659.
James A. Campbell argued the cause for petitioner. With
him on the briefs were Kristen K. Waggoner, Barry K. Ar-
rington, Shaun Pearman, John J. Bursch, David A. Cort-
man, Erin M. Hawley, Caroline C. Lindsay, Jonathan A.
Scruggs, Jacob P. Warner, Roger G. Brooks, and Bryan D.
Neihart.
Principal Deputy Solicitor General Moopan argued the
cause for the United States as amicus curiae supporting
petitioner. With him on the brief were Solicitor General
Sauer, Assistant Attorney General Shumate, Zoe A. Jacoby,
Michael S. Raab, and Lowell V. Sturgill, Jr.
Shannon Wells Stevenson, Solicitor General of Colorado, ar-
gued the cause for respondents. With her on the brief were
Philip J. Weiser, Attorney General of Colorado, Helen Norton,
Deputy Solicitor General, Andrew M. Williams, Assistant
Deputy Attorney General, Robert W. Finke, First Assistant
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631
Counsel
Attorney General, and Janna K. Fischer, Abby Chestnut,
and
Talia Kraemer, Assistant Solicitors General, and Bri-
anna S. Tancher, Assistant Attorney General.*
*Briefs of amici curiae urging reversal were fled for the State of Iowa
et al. by Brenna Bird, Attorney General of Iowa, Eric Wessan, Solicitor
General, and by the Attorneys General for their respective States as fol-
lows: Steve Marshall of Alabama, Treg Taylor of Alaska, Tim Griffn of
Arkansas, James Uthmeier of Florida, Chris Carr of Georgia, Raúl R.
Labrador of Idaho, Kris Kobach of Kansas, Russell M. Coleman of Ken-
tucky, Liz Murrill of Louisiana, Andrew T. Bailey of Missouri, Austin
Knudsen of Montana, Michael T. Hilgers of Nebraska, Drew Wrigley of
North Dakota, Dave Yost of Ohio, Gentner Drummond of Oklahoma, Alan
Wilson of South Carolina, Marty Jackley of South Dakota, Ken Paxton of
Texas, and John B. McCuskey of West Virginia; for the Alliance for Thera-
peutic Choice and Scientifc Integrity by Nicholas P. Miller; for the Amer-
ican College of Pediatricians by Gene C. Schaerr, Edward H. Trent, and
John Greil; for the American Unity Fund et al. by Megan M. Wold; for
the Americans for Prosperity Foundation et al. by Cynthia Fleming
Crawford, Casey Mattox, James L. Kerwin, and William E. Trachman;
for America's Frontline Doctors et al. by David A. Dalia; for America's
Future et al. by William J. Olson, Jeremiah L. Morgan, and Joseph W.
Miller; for the Anglican Church in North America et al. by R. Shawn
Gunnarson and Christopher A. Bates; for the Association of American
Physicians and Surgeons by Andrew L. Schlafy; for the Association of
Certifed Biblical Counselors by Michael S. Overing, Edward C. Wilde,
and Itzel Morales; for the Becket Fund for Religious Liberty by Adèle A.
Keim, Luke W. Goodrich, Rebekah P. Ricketts, Benjamin A. Fleshman,
and Amanda G. Dixon; for Catholic Licensed Counselors et al. by Freder-
ick W. Claybrook, Jr.; for the CatholicVote.org Education Fund by Scott
W. Gaylord; for the Changed Movement by Samuel J. Salario, Jr.; for the
Christian Family Coalition (CFC) Florida, Inc., by Dennis Grossman; for
the Christian Legal Society by Steven T. McFarland, Laura Nammo, Lori
Kepner, and Dustin D. Romney; for the Colson Center for Christian
Worldview et al. by Michael Francisco and Andrew Nussbaum; for Do
No Harm, Inc., by David H. Thompson and Brian W. Barnes; for the
Family Research Council et al. by Christopher E. Mills; for First Amend-
ment Scholars by William H. Hurd and Michael W. Thomas; for the Foun-
dation for Moral Law by John A. Eidsmoe; for the Frontline Policy Council
et al. by Kristine L. Brown; for Heartbeat International by Patrick Straw-
bridge, Tiffany H. Bates, Kelly J. Shackel ford, Jeffrey C. Mateer, David J.
Hacker, and Jeremiah G. Dys; for the Institute for Free Speech by Owen

632 CHILES
v. SALAZAR
Opinion of the Court
Justice Gorsuch delivered the opinion of the Court.
Ka
ley Chiles is a mental-health counselor in Colorado. In
this case, we consider her First Amendment challenge to a
Yeates; for Jaco Booyens Ministries (JBM) et al. by Frank J. Wright; for
Legislators from 30 State Legislatures by William Wagner; for Liberty
Counsel by Mathew D. Staver, Anita L. Staver, and Horatio G. Mihet; for
the Liberty Justice Center by Jeffrey Schwab; for the Manhattan Institute
et al. by Ilya Shapiro and Howard Slugh; for Medical Professionals by
John C. Sullivan and Robert P. George; for the National Association of
Scholars by Dennis J. Saffran; for National Religious Broadcasters by
Michael P. Farris; for the NC Values Institute et al. by Deborah J. Dew-
art, Tami Fitzgerald, and Robert H. Tyler; for Our Duty-USA et al. by Dan-
iel Cragg; for the Pacifc Legal Foundation by Ethan W. Blevins and Caleb
R. Trotter; for Sexual Orientation Scholars by Jonathan R. Whitehead;
for the United States Conference of Catholic Bishops et al. by Nicholas J.
Nelson; for the Women's Liberation Front by Elspeth B. Cypher; for Erin
Brewer et al. by Renee K. Carlson and Douglas G. Wardlow; for Joy Buch-
man et al. by Luke N. Berg and Richard M. Esenberg; for Sexuality Re-
search Scholar Amy E. Hamilton by Randall L. Wenger and Janice L.
Martino-Gottshall; for Mary Hasson et al. by Thomas Brejcha; for
Anthony M. Joseph by Allan E. Parker, Jr., R. Clayton Trotter, and
Steven W. Fitschen; and for David A. Robinson, pro se. Robert J. Mc-
Namara, Samuel B. Gedge, Andrew Ward, Michael N. Greenberg, Jeffrey
T. Rowes, and Paul V. Avelar fled a brief for Parties in Other First
Amendment Cases Pending Before the Court urging vacatur and
remand.
Briefs of amici curiae urging affrmance were fled for the State of
Washington et al. by Nicholas W. Brown, Attorney General of Washing-
ton, Noah G. Purcell, Solicitor General, Cristina Sepe, Deputy Solicitor
General, and by the Attorneys General for their respective jurisdictions as
follows: Rob Bonta of California, William Tong of Connecticut, Kathleen
Jennings of Delaware, Brian L. Schwalb of the District of Columbia, Anne
E. Lopez of Hawaii, Kwame Raoul of Illinois, Aaron M. Frey of Maine,
Anthony G. Brown of Maryland, Andrea Joy Campbell of Massachusetts,
Dana Nessel of Michigan, Keith Ellison of Minnesota, Aaron D. Ford of
Nevada, Matthew J. Platkin of New Jersey, Raúl Torrez of New Mexico,
Letitia James of New York, Jeff Jackson of North Carolina, Dan Rayfeld
of Oregon, Peter F. Neronha of Rhode Island, Charity R. Clark of Ver-
mont, and Joshua L. Kaul of Wisconsin; for the American Psychological
Association et al. by Jessica Ring Amunson, Deanne M. Ottaviano, and
Aaron M. Panner; for the Constitutional Accountability Center by Eliza-
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Opinion of the Court
state law regulating what she may say when speaking with
her
clients.
beth B. Wydra, Brianne J. Gorod, and David H. Gans; for Constitutional
Law and First Amendment Scholars by Thomas S. Kessler, Luke A. Bare-
foot, and Sarah E. Libowsky; for the Conversion Therapy Survivor Net-
work et al. by Shayna Medley, Ezra Cukor, and Katherine Rosen feld; for
Experts in Health Care Practice et al. by Craig Konnoth, Lisa Linsky,
and Jared Gerber; for Faith-Based Mental Health Professionals by Paul
Alessio Mezzina, Amy R. Upshaw, and Sean P. Madden; for the Fred T.
Korematsu Center for Law and Equality et al. by Paul F. Rugani, Nicole
Ries Fox, Shane McCammon, and Robert S. Chang; for Health Law Schol-
ars by Cynthia Cheng-Wun Weaver, Ami R. Patel, and John Paul
Schnapper-Casteras; for Legal Ethics Professors by Melissa C. Cassel; for
Medical History Scholars et al. by Kendra N. Beckwith; for Members of Con-
gress by Conor Tucker and Jefferson Klocke; for PFLAG, Inc., et al. by Jo-
seph H. Lang, Jr., and Nancy J. Faggianelli; for Parents of Conversion-
Therapy Participants et al. by Parker Rider-Longmaid, Steven Marcus, and
Hanaa Khan; for Professors of Law et al. by Kathleen R. Hartnett, Patrick
J. Hayden, Raymond P. Tolentino, and Joshua Revesz; for Religious Organi-
zations by Amy Tai; for the Trevor Project, Inc., et al. by Abbey Hudson,
Amer S. Ahmed, Kelly Herbert, Shireen A. Barday, and Stuart F. Delery;
for Guy Albert, Ph.D., by Alice W. Yao and Mary Rohmiller; for Interna-
tional Law Scholar Paul Behrens by Sonia Miller-Van Oort; for Gregory
Coles et al. by William L. Harbison; for Ryan M. Kendall et al. by Sarah
Austin and Patience Crozier; for David Palmieri et al. by Mark W. Fried-
man and Justin R. Rassi; for Mathew Shurka by Ross M. Bagley and
Meghan E. Hill; for Dr. Jack L. Turban MD, MHS, et al. by John M.
McHugh; and for 27+ Lay Roman Catholics by James K. Riley, pro se.
Briefs of amici curiae were fled for the American Association of Chris-
tian Counselors et al. by Sean P. Gates; for the Christian Medical and
Dental Associations et al. by Kristine L. Brown; for Former Conversion
Therapy Leaders by Laura Landenwich; for the Freedom From Religion
Foundation by Patrick Elliott; for the International Foundation for Thera-
peutic and Counseling Choice by William Bock III; for Land-Surveyor
and Civil-Engineer Trade Associations by Jens B. Koepke and Steve
Hirsch; for the LONANG Institute by Kerry Lee Morgan and Randall A.
Pentiuk; for the UCLA School of Law Williams Institute Scholars by S.
Douglas Bunch and Ryan Wheeler; for Randy Elf, pro se; for Erin Lee
et al. by J. Brad Bergford; for Joseph Nicolosi, Jr., Ph.D., et al. by Jeffrey
M. Trissell, Charles S. LiMandri, Paul M. Jonna, and Thomas Brejcha;
for Clifford J. Rosky et al. by Veronica Percia and Whitney Pellegrino;
and for Eugene Volokh, pro se.

634 CHILES
v. SALAZAR
Opinion of the Court
I
A
A
ccording to Ms. Chiles's verifed complaint, she holds a
master's degree in clinical mental health and a state counsel-
ing license. App. to Pet. for Cert. 212a (App.). Clients
seek her help on a wide variety of mental-health issues, in-
cluding trauma, addiction, “eating disorders, gender dyspho-
ria[,] and sexuality.” Id., at 206a–207a, 215a. Ms. Chiles
“does not begin counseling ” on any topic “with any predeter-
mined goals.” Id., at 207a. Nor does she seek to “impose
her values or beliefs” on clients. Id., at 212a. Instead, she
“sits down . . . and talks to them about their goals.” Id., at
207a; see also id., at 213a. Only after clients have identifed
their own aspirations does Ms. Chiles begin “formulat[ing]
methods of counseling that will most beneft” them. Id., at
207a. In any counseling that follows, as well, Ms. Chiles
seeks to respect her “clients' fundamental right of self-
determination.” Ibid.
On matters of sexuality and gender, Ms. Chiles's clients,
including minors, come to her with different goals in mind.
Some “are content with” their sexual orientation and gender
identity and seek assistance only with “social issues, family
relationships,” and the like. Id., at 207a, 213a–214a. In
cases like those, Ms. Chiles does not try to persuade her
clients to “change their attractions, behavior, or identity,”
but aims instead to help them address their stated goals.
Id., at 214a; see also id., at 207a. Other clients, however,
come to her hoping to “reduce or eliminate unwanted sexual
attractions, change sexual behaviors, or grow in the experi-
ence of harmony with [their] bod[ies].” Ibid. And in these
cases, too, Ms. Chiles seeks to help her clients reach their
own stated objectives. Ibid. In doing so, she does not pre-
scribe any medicines, perform any physical treatments, or
engage in any coercive or aversive practices. Id., at 205a–
207a. All Ms. Chiles offers is talk therapy. Ibid.
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B
In
2019, Colorado adopted a law prohibiting licensed coun-
selors from engaging in “conversion therapy” with minors.
Colo. Rev. Stat. § 12–245–224(1)(t)(V) (2025). The State re-
ports that it adopted the law “in response to a growing men-
tal health crisis among Colorado teenagers and mounting evi-
dence that conversion therapy is associated with increased
depression, anxiety, suicidal thoughts, and suicide attempts.”
Brief for Respondents 11–12. Any Coloradan who thinks a
licensed counselor is engaging in conversion therapy may
fle a complaint with a regulatory board. See § 12–245–
226(1)(a)(II)(B). A complaint, in turn, triggers a discipli-
nary review process that can yield a fne, probation, or the
loss of a license. See § 12–245–225; Brief for Respondents 9.
The term “conversion therapy” may evoke physical tech-
niques such as “ `electric shoc[k]' ” therapy aimed at chang-
ing an individual's sexual orientation or gender identity.
Id., at 4. But Colorado's ban on conversion therapy reaches
further, forbidding “any practice or treatment . . . that
attempts . . . to change an individual's sexual orientation
or gender identity.” § 12–245–202(3.5)(a) (emphasis added).
The law forbids as well any “effor[t ] to change behaviors or
gender expressions or to eliminate or reduce sexual or ro-
mantic attraction or feelings toward individuals of the same
sex.” Ibid. At the same time, the law explicitly allows
counselors to engage in “practices” that provide “[a]ccept-
ance, support, and understanding for the facilitation of an
individual's . . . identity exploration and development.”
§ 12–245–202(3.5)(b)(I). Likewise, the law allows counselors
to provide “[a]ssistance to a person undergoing gender tran-
sition.” § 12–245–202(3.5)(b)(II).
After Colorado adopted its new law, Ms. Chiles fled suit
in federal court and sought a preliminary injunction prohibit-
ing the State from enforcing it against her. She did not dis-
pute that the statute has many valid applications. Indeed,
Ms. Chiles did not take issue with Colorado's effort to ban
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636 CHILES
v. SALAZAR
Opinion of the Court
what she herself calls “long-abandoned, aversive” physical
i
nterventions. Brief for Petitioner 10. Instead, Ms. Chiles
objected to Colorado's law only as it applies to her talk ther-
apy, therapy that involves no physical interventions or medi-
cations, only the spoken word. Motion for Preliminary
Injunction in No. 22–cv–2287 (D Colo.), ECF Doc. 29, pp. 2–
3, 15.
Ms. Chiles's as-applied challenge ran this way. With re-
spect to gender identity, she claimed, the law permits her to
speak in ways that encourage a client “ `undergoing gender
transition,' ” but the law prohibits her from speaking in ways
that help a client “realign [his] identity with [his] sex.”
Brief for Petitioner 11; see ECF Doc. 29, at 17–20. With
respect to sexual orientation, Ms. Chiles continued, Colora-
do's law similarly allows her to affrm a client's sexual orien-
tation, but prohibits her from speaking in any way that helps
a client “change” his sexual attractions or behaviors. Brief
for Petitioner 11; see ECF Doc. 29, at 17–20. Even though
Colorado's law surely has other constitutional applications,
she insisted, these constraints strip her of her First Amend-
ment right to speak freely with her clients in ways she be-
lieves might help them meet “their own goals.” Brief for
Petitioner 12; see ECF Doc. 29, at 2–3.
C
Both the district court and the Tenth Circuit determined
that Ms. Chiles had Article III standing to pursue her as-
applied pre-enforcement challenge. 116 F. 4th 1178, 1199,
1201 (2024); Civ. Action No. 1:22–cv–2287 (D Colo., Dec. 19,
2022), App. 139a.
In support of their conclusion, both courts read Colorado's
law as prohibiting licensed counselors like Ms. Chiles from
engaging in any attempt—including through speech—to help
a minor client change his gender identity or sexual orienta-
tion. 116 F. 4th, at 1197; App. 141a–142a. Both courts un-
derstood this prohibition as extending to any attempt—in-

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cluding through speech—to change a client's “behaviors or
gender
expressions or to eliminate or reduce sexual or ro-
mantic attraction or feelings toward individuals of the same
sex.” § 12–245–202(3.5)(a); see 116 F. 4th, at 1197; App.
141a–142a. As both courts saw it, too, Ms. Chiles had pre-
viously spoken in ways the law now forbids, and she would
continue speaking the same way but for Colorado's new law.
116 F. 4th, at 1196–1198; App. 141a–142a. Finally, both
courts concluded that Ms. Chiles had alleged a “credible
threat” that the State would enforce its law against her if
she continued speaking as she had in the past and wished to
do in the future. Indeed, both courts observed, Colorado
authorities had refused to disavow bringing enforcement ac-
tions against her. 116 F. 4th, at 1198–1199; App. 142a–144a.
Under these circumstances, the courts held, Ms. Chiles
faced an “ongoing injury resulting from the statute's chilling
effect” on her speech. 116 F. 4th, at 1195 (internal quotation
marks omitted); see App. 140a–141a. Satisfed as well that
Ms. Chiles's injury was traceable to Colorado's law and re-
dressable by an as-applied constitutional ruling in her favor,
both courts held that she possessed Article III standing to
bring suit. 116 F. 4th, at 1194, 1199; App. 145a, n. 5. In
coming to this conclusion, the lower courts joined others that
have found standing in similar cases involving similar stat-
utes. See, e. g., Tingley v. Ferguson, 47 F. 4th 1055, 1066
(CA9 2022); Catholic Charities of Jackson, Lenawee and
Hillsdale Ctys. v. Whitmer, 162 F. 4th 686, 691 (CA6 2025).*
*We, too, agree that Ms. Chiles has standing. Before us, Colorado only
half heartedly contests the point, suggesting Ms. Chiles cannot establish a
present “intention” to speak in a way the law forbids. Brief for Respond-
ents 23, n. 18. But the State's argument is based not on some new insight
about Ms. Chiles's state of mind, only a new and narrowed construction of
the statute that the State advances for the frst time in this Court. Id.,
at 18–19. Colorado's late-breaking construction of its law, however, would
render much of the law's language superfuous. Reply Brief 2–6; People
v. Rodriguez-Morelos, 562 P. 3d 71, 73 (Colo. 2025) (reciting the presump-
tion against surplusage when construing state statutes). The State's new

638 CHILES
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Turning to the merits, both the district court and the
T
enth Circuit denied Ms. Chiles's request for a preliminary
injunction. The courts recognized that Ms. Chiles provides
only “talk therapy.” 116 F. 4th, at 1193; see App. 152a.
And they acknowledged that Colorado's law regulates the
“verbal language” she may use. 116 F. 4th, at 1208; see App.
152a. But, the courts held, the main thrust of the State's
law is to delineate which “treatments” and “therapeutic mo-
dalit[ies]” are permissible. 116 F. 4th, at 1208, 1210; see
App. 151a. Accordingly, the courts reasoned that Colorado's
law is best understood as regulating “professional conduct.”
116 F. 4th, at 1206, 1208, 1214; see App. 151a, 155a. At most,
they continued, Colorado's law regulates speech only “inci-
dentally” to professional conduct. 116 F. 4th, at 1204; see
App. 155a. As a result, the courts concluded, Colorado's law
triggers no more than “rational basis review” under the First
Amendment, requiring the State to show merely that its law
is rationally related to a legitimate governmental interest.
116 F. 4th, at 1215; App. 156a. Because the State satisfed
that standard, the courts held that Ms. Chiles was not enti-
tled to the relief she sought. 116 F. 4th, at 1220–1221;
App. 157a.
At the Tenth Circuit, Judge Hartz dissented. As he saw
it, the majority committed “several fundamental errors.”
116 F. 4th, at 1227. While Colorado's law may ban conduct
in other applications, he observed, with respect to Ms. Chiles
it regulates only what she may and may not say. Id., at
interpretation also seemingly stands at odds with how the State itself
understood its law in proceedings below. See, e. g., Motion to Dismiss
Complaint in No. 22–cv–2287 (D Colo.), ECF Doc. 52, p. 5, n. 3. Sepa-
rately, Colorado suggests that Ms. Chiles has not shown a credible threat
that the State will enforce its law against her. Brief for Respondents 23,
n. 18. But Colorado has fought this suit through three courts over three
years and, at argument here, expressly declined to disavow enforcement
against Ms. Chiles. Tr. of Oral Arg. 80–81. As the lower courts held, no
more is required under this Court's precedents. 116 F. 4th, at 1199; App.
145a; see Susan B. Anthony List v. Driehaus, 573 U. S. 149, 159 (2014).
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1231. And under this Court's precedents, he argued, that
k
ind of speech regulation triggers far more demanding scru-
tiny than mere rational-basis review. Id., at 1226–1229.
Nor, Judge Hartz continued, does the fact that Ms. Chiles
happens to hold a professional license change the equation.
Id., at 1229–1230. To the contrary, he said, the majority's
effort to recast Ms. Chiles's speech as “professional conduct”
amounted to little more “than a labeling game.” Id., at 1231
(internal quotation marks omitted).
After the Tenth Circuit ruled, Ms. Chiles sought certio-
rari. In doing so, she argued that the Tenth Circuit's deci-
sion “worsened a circuit confict” over how the First Amend-
ment interacts with laws like Colorado's. Pet. for Cert. 16;
compare 116 F. 4th, at 1221, and Tingley, 47 F. 4th, at 1077,
with Catholic Charities of Jackson, 162 F. 4th, at 696; Otto
v. Boca Raton, 981 F. 3d 854, 868–870 (CA11 2020); King v.
Governor of New Jersey, 767 F. 3d 216, 229 (CA3 2014), abro-
gated in part by National Institute of Family and Life Ad-
vocates v. Becerra, 585 U. S. 755, 767–769 (2018) (NIFLA);
Tingley v. Ferguson, 57 F. 4th 1072, 1083–1085 (CA9 2023)
(Bumatay, J., dissenting from denial of rehearing en banc).
We agreed to hear the case. 604 U. S. 1193 (2024).
II
The question before us is a narrow one. Ms. Chiles does
not question that Colorado's law banning conversion therapy
has some constitutionally sound applications. See Brief for
Petitioner 53. She does not take issue with the State's
effort to prohibit what she herself calls “long-abandoned, av-
ersive” physical interventions. Id., at 10. Instead, Ms.
Chiles stresses that she provides only talk therapy, employ-
ing no physical techniques or medications. Yet, she argues,
Colorado's law still applies to her, prescribing what she may
say in “voluntary counseling conversations” with her clients.
Id., at 50. And because that application of the law strikes
at the heart of the First Amendment's protections for free
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speech, she contends, it warrants considerably more search-
i
ng scrutiny than the rational-basis review the Tenth Circuit
applied in this case or the intermediate-scrutiny review some
other lower courts have employed in cases like hers. Id., at
38; see, e. g., King, 767 F. 3d, at 237. We agree. To explain
why, we begin by outlining the relevant First Amendment
principles that govern us before discussing how they apply
here.
A
The First Amendment “envisions the United States as a
rich and complex place” where all enjoy the “ `freedom to
think as you will and to speak as you think.' ” 303 Creative
LLC v. Elenis, 600 U. S. 570, 584, 603 (2023) (quoting Boy
Scouts of America v. Dale, 530 U. S. 640, 660–661 (2000)).
Often, speech may prove illuminating and inspiring. Some-
times, it can be misguided, offensive, or cause “incalculable
grief.” Snyder v. Phelps, 562 U. S. 443, 456 (2011). But
either way, the First Amendment protects the inalienable
right of every individual to decide for himself “how best to
speak.” Riley v. National Federation of Blind of N. C.,
Inc., 487 U. S. 781, 791 (1988). In this Nation, no offcial—
“high or petty”—may command our tongues or silence our
voices. West Virginia Bd. of Ed. v. Barnette, 319 U. S. 624,
642 (1943).
Consistent with the First Amendment's jealous protec-
tions for the individual's right to think and speak freely, this
Court has long held that laws regulating speech based on its
subject matter or “communicative content” are “presump-
tively unconstitutional.” Reed v. Town of Gilbert, 576 U. S.
155, 163 (2015). As a general rule, such “content-based” re-
strictions trigger “strict scrutiny,” a demanding standard
that requires the government to prove its restriction on
speech is “narrowly tailored to serve compelling state inter-
ests.” Ibid. Under that test, it is “ `rare that a regulation
. . . will ever be permissible.' ” Brown v. Entertainment
Merchants Assn., 564 U. S. 786, 799 (2011) (quoting United
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States v. Playboy Entertainment Group, Inc., 529 U. S. 803,
818
(2000)).
We have recognized, as well, the even greater dangers as-
sociated with regulations that discriminate based on the
speaker's point of view. When the government seeks not
just to restrict speech based on its subject matter, but also
seeks to dictate what particular “opinion or perspective” in-
dividuals may express on that subject, “the violation of the
First Amendment is all the more blatant.” Rosenberger v.
Rector and Visitors of Univ. of Va., 515 U. S. 819, 829 (1995).
“Viewpoint discrimination,” as we have put it, represents “an
egregious form” of content regulation, and governments in
this country must nearly always “abstain” from it. Ibid.;
see also Iancu v. Brunetti, 588 U. S. 388, 393 (2019) (describ-
ing “the bedrock First Amendment principle that the gov-
ernment cannot discriminate” based on viewpoint (internal
quotation marks omitted)); Good News Club v. Milford Cen-
tral School, 533 U. S. 98, 112–113 (2001); Barnette, 319 U. S.,
at 642.
Of course, with almost any rule comes exceptions. And
this Court has recognized a “few historic and traditional
categories of expression long familiar to the bar” where
content-based restrictions on speech will not automatically
trigger strict scrutiny—categories that include fraud,
defamation, and “fghting words.” United States v. Alvarez,
567 U. S. 709, 717 (2012) (plurality opinion) (alterations and
internal quotation marks omitted). But, as we have taken
pains to emphasize, these exceptional categories are few and
narrowly drawn, and all share a long and wellrecognized his-
torical pedigree. Ibid.; see NIFLA, 585 U. S., at 767. In-
deed, even within these categories we have sometimes still
applied strict scrutiny when governments have sought to
regulate speech based on viewpoint. See, e. g., R. A. V. v.
St. Paul, 505 U. S. 377, 392, 395–396 (1992) (addressing an
ordinance that barred certain “fghting words” based on
viewpoint).
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From these general principles, other more specifc ones fol-
low
. So, for example, a law regulating the content of speech
cannot avoid searching First Amendment review just be-
cause it mostly regulates non-expressive conduct. Take a
classic illustration: Cohen v. California, 403 U. S. 15 (1971).
There, the State of California charged Paul Cohen with “ma-
liciously and willfully disturb[ing] the peace.” Id., at 16 (in-
ternal quotation marks omitted). Often, of course, a person
disturbs the peace through conduct alone (say, by brawling
at a city council meeting). But that is not always true.
And in Mr. Cohen's case, California charged him for disturb-
ing the peace because he wore a jacket bearing the words
“ `Fuck the Draft' ” in the corridor of a municipal courthouse.
Ibid. As applied to him, the Court recognized, the law im-
plicated core First Amendment concerns because the only
“ `conduct' ” he engaged in was the speech he displayed. Id.,
at 18. And, we held, California could not constitutionally
punish him because of the “content” of his message. Ibid.
We repeated the point in Holder v. Humanitarian Law
Project, 561 U. S. 1 (2010). That case involved a federal law
banning the provision of “ `material support' ” to certain for-
eign terrorist organizations. Id., at 8–9. Much as Califor-
nia had in Cohen, the federal government in Holder argued
that the law did not trigger strict scrutiny because it ad-
dressed “conduct, not speech.” 561 U. S., at 26. We dis-
agreed. True, we acknowledged, the law often might regu-
late conduct. But, we observed, in the case before us the
government threatened to prosecute lawyers, doctors, and
others for providing spoken training and expert advice (such
as “ `how to use humanitarian and international law to peace-
fully resolve disputes' ”) to certain groups. Id., at 16, 21–22.
And that application of the law, we held, sought to “regulat[e]
speech on the basis of its content” and thus demanded strict-
scrutiny review. Id., at 27–28.
As Holder indicates, too, the First Amendment's protec-
tions extend to licensed professionals much as they do to
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everyone else. It's a point we have since discussed at length
i
n NIFLA. There, California sought to require crisis preg-
nancy clinics to make certain statements to their clients.
The State argued that its law did not trigger demanding
First Amendment review because it sought to regulate only
“ `professional speech' ” by state license holders. 585 U. S.,
at 766–767. We rejected that move. By compelling clinics
to speak the State's message, the law regulated speech based
on its content. Id., at 766. And, we held, California had
failed to “identif[y] a persuasive reason for treating profes-
sional speech as a unique category . . . exempt from ordinary
First Amendment principles.” Id., at 773.
In reaching that conclusion, to be sure, we acknowledged
two kinds of content-based restrictions that can apply to pro-
fessional speech without triggering strict scrutiny. First,
courts generally deploy less searching review when faced
with laws that require speakers to disclose only factual, non-
controversial information in “ `commercial speech.' ” Id., at
768; Zauderer v. Offce of Disciplinary Counsel of Supreme
Court of Ohio, 471 U. S. 626, 650–653 (1985). Second, laws
regulating conduct in ways that incidentally sweep in speech
may also generally avoid strict scrutiny. NIFLA, 585 U. S.,
at 769. As with laws addressing fraud, defamation, and
“fghting words,” laws regulating speech along these two
lines enjoy a long historical tradition. Id., at 767. But, we
stressed, neither “turn[s] on the fact” that a licensed profes-
sional happens to be speaking. Id., at 768. Nor, we empha-
sized, do these narrow categories of lesser-protected speech
warrant a new rule exempting a broader “category called
`professional speech' ” from demanding First Amendment re-
view. Ibid.
B
Applying these principles, we conclude that the courts
below failed to apply suffciently rigorous First Amendment
scrutiny in this case.
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Start with the most obvious point. While the First
Amendment
protects many and varied forms of expression,
the spoken word is perhaps the quintessential form of pro-
tected speech. And that is exactly the kind of expression in
which Ms. Chiles seeks to engage. As a talk therapist, all
Ms. Chiles does is speak with clients; she does not prescribe
medication, use medical devices, or employ any physical
methods. App. 205a–207a.
Next, and nearly as clear to our eyes, Colorado seeks to
regulate the content of Ms. Chiles's speech. When it comes
to issues of human sexuality, some of her clients “are content
with” their sexual identity and orientation and want help
only “with social issues [or] family relationships.” Id., at
207a, 214a. But other clients seek her counsel on how to
“reduce or eliminate unwanted sexual attractions, change
sexual behaviors, or grow in the experience of harmony with
[their] bod[ies].” Id., at 207a. And in those cases, Colorado
regulates how Ms. Chiles may respond. Under its law, she
may not speak in any way that attempts to change a client's
“sexual orientation or gender identity”—including a client's
“behaviors or gender expressions”—or in any way that seeks
to “eliminate or reduce” a client's “sexual or romantic at-
traction or feelings toward individuals of the same sex.”
§ 12–245–202(3.5)(a).
Doubtless, Colorado sees things differently. The State in-
sists, and the Tenth Circuit agreed, that its law does not
“regulate expression” at all, only “conduct,” “treatment,” or
a “therapeutic modality.” Brief for Respondents 2, 36–37,
47; 116 F. 4th, at 1208. As a result, Colorado reasons, its
law triggers no more than rational-basis or intermediate-
scrutiny review. Brief for Respondents 42–44. But the
State's premise is simply mistaken. In many applications,
the State's law banning “conversion therapy” may address
conduct—such as aversive physical interventions. But here,
Ms. Chiles seeks to engage only in speech, and as applied to
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her the law regulates what she may say. Her speech does
not
become conduct just because the State may call it that.
Nor does her speech become conduct just because it can also
be described as a “treatment,” a “therapeutic modality,” or
anything else. The First Amendment is no word game.
And the rights it protects cannot be renamed away or their
protections nullifed by “mere labels.” NAACP v. Button,
371 U. S. 415, 429 (1963).
Our precedents have long made that much clear. Califor-
nia faulted Mr. Cohen for the “conduct” of wearing an offen-
sive jacket. Cohen, 403 U. S., at 16. The federal govern-
ment insisted that its law banning support to terrorists
regulated “conduct” even as applied to the written and
spoken advice of professionals like lawyers and doctors.
Holder, 561 U. S., at 10, 26. But the effort to recast speech
as conduct failed in those cases—and it must here too.
Under the First Amendment, what matters is not how a gov-
ernment describes its law or whether the law may regulate
conduct in other circumstances. What matters is whether,
in fact, the law regulates speech in the case at hand.
As applied here, Colorado's law does not just regulate the
content of Ms. Chiles's speech. It goes a step further, pre-
scribing what views she may and may not express. For a
gay client, Ms. Chiles may express “[a]cceptance, support,
and understanding for the facilitation of . . . identity explora-
tion.” § 12–245–202(3.5)(b)(I). For a client “undergoing
gender transition,” Ms. Chiles may likewise offer words of
“[a]ssistance.” § 12–245–202(3.5)(b)(II). But if a gay or
transgender client seeks her counsel in the hope of changing
his sexual orientation or gender identity, Ms. Chiles cannot
provide it. The law forbids her from saying anything that
“attempts . . . to change” a client's “sexual orientation or
gender identity,” including anything that might represent an
“effor[t] to change [her client's] behaviors or gender expres-
sions or . . . romantic attraction[s].” § 12–245–202(3.5)(a).
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Colorado disputes none of this; neither does the dissent.
See
post, at 677–678 (opinion of Jackson, J.) (acknowledging
that Colorado has engaged in viewpoint discrimination).
Of course, Ms. Chiles remains free to say other things.
As Colorado and the dissent emphasize, she may “shar[e] in-
formation” about sexual orientation or gender identity.
Brief for Respondents 20. She can “criticiz[e] Colorado's
law.” Ibid. She can “writ[e] papers” espousing her views.
Post, at 677 (opinion of Jackson, J.). She may even encour-
age a client to seek advice from someone else who doesn't
hold a state license. Brief for Respondents 20. But true as
all that may be, it is also true that she cannot voice certain
“perspective[s]” the State disfavors when speaking with con-
senting clients. Rosenberger, 515 U. S., at 829. And, under
our precedents, viewpoint restrictions like that are not sub-
ject to mere rational-basis review or intermediate scrutiny.
Rather, they represent “an egregious form of content dis-
crimination” where First Amendment concerns are at their
most “blatant.” Ibid.; see also Reed, 576 U. S., at 168–169;
contra, post, at 666, 677–679 (Jackson, J., dissenting) (con-
tending that “heightened scrutiny . . . is not warranted” even
while admitting that Colorado's law discriminates based on
viewpoint).
The fact that the State's viewpoint regulation targets only
licensed healthcare professionals like Ms. Chiles changes
nothing. Colorado and the dissent may believe that the
First Amendment should carry “far less salience” for the Na-
tion's millions of “medical professionals” than for everyone
else. Post, at 646 (opinion of Jackson, J.); post, at 674–683;
Brief for Respondents 23. They may believe that state-im-
posed orthodoxies in speech pose few dangers and many bene-
fts in this feld (and who knows what others). But their policy
is not the First Amendment's. The Constitution does not pro-
tect the right of some to speak freely; it protects the right of
all. It safeguards not only popular ideas; it secures, even and
especially, the right to voice dissenting views. Consist-
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ent with these principles, our precedents have expressly re-
jec
ted the State and dissent's notion that “professional
speech” represents some “separate category of speech” sub-
ject to “diminished constitutional protection.” NIFLA, 585
U. S., at 767 (internal quotation marks omitted). History is
littered with examples of offcial efforts to manipulate and
control professional speech—including “the content of
doctor-patient discourse”—in ways designed “to increase
state power,” “suppress minorities,” and muzzle “unpopular
ideas.” Id., at 771 (internal quotation marks omitted) (re-
counting examples). And the “dangers associated with”
censorship, we have recognized, are no less acute “in the
felds of medicine and public health” than they are anywhere
else. Ibid. (internal quotation marks omitted).
Nor does Colorado's law implicate any recognized excep-
tion to our usual First Amendment rules. As we have seen,
some laws regulating speech based on its content—like ones
addressing fraud, defamation, and “fghting words”—do not
generally trigger heightened scrutiny because of their long
historical pedigree. See Part II–A, supra. As we have
seen, too, NIFLA recognized that two kinds of such laws
sometimes apply to professionals. See 585 U. S., at 768.
But Colorado's law fts in neither category. The State does
not require professionals to disclose “factual, noncontrover-
sial information in their commercial speech.” Ibid. (internal
quotation marks omitted). Instead, Colorado seeks to sup-
press views Ms. Chiles wishes to express. Nor, with re-
spect to Ms. Chiles, does Colorado's law regulate conduct in
a way that only “incidentally burden[s] speech.” Id., at 769.
All Ms. Chiles does is speak—and, as far as she is concerned,
speech is all Colorado seeks to regulate.
Resisting this conclusion, Colorado and the dissent try to
shoehorn the State's statute into the latter category. See,
e. g., Brief for Respondents 37. By defning prohibited “con-
version therapy” broadly, Colorado observes, its law pro-
scribes a “wide range” of “treatments.” Id., at 18. Any
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activity that seeks to change a client's gender identity or
sexua
l orientation—whether it involves “electric shocks” or
consists of “words only”—is banned. Ibid. And consider-
ing the full scope of the law's many applications, the State
submits, it seeks to regulate mostly conduct and reaches
speech only incidentally. Ibid. The dissent pursues a simi-
lar theme, insisting that Colorado has only incidentally pro-
hibited Ms. Chiles's speech because the law's “primary objec-
tive” is to regulate medical treatments. Post, at 666–683
(opinion of Jackson, J.).
This argument echoes Colorado's claim that it seeks to reg-
ulate only conduct, and they falter for similar reasons. If a
government could reclassify talk therapy as speech incident
to conduct, it might just as easily do the same for speech
incident to “teaching or protesting.” Otto, 981 F. 3d, at 865.
“[B]oth are activities, after all.” Ibid. Were that the rule,
“[w]hat an opportunity for [the] suppression of dissent this
would offer.” 116 F. 4th, at 1228 (Hartz, J., dissenting).
Governments could easily wield all manner of laws regulat-
ing some conduct to silence speech they disfavor. It is a
result that would not “compor[t] with the First Amend-
ment's animating principles” so much as betray them. Con-
tra, post, at 674 (Jackson, J., dissenting).
Recognizing as much, our precedents in Cohen and Holder
already foreclose exactly this move. California prosecuted
Mr. Cohen under a law banning disturbances of the peace.
Cohen, 403 U. S., at 16. The federal government threatened
lawyers and doctors with prosecution under a law prohibit-
ing support for terrorists. Holder, 561 U. S., at 10, 14–15,
25. In both cases, the government defended its actions on
the ground that the law in question was generally aimed at
certain types of conduct. But in both cases, we emphati-
cally rejected that argument. Just because a law may “gen-
erally functio[n] as a regulation of conduct,” we held, does
not exempt it from demanding First Amendment review
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when a government seeks to apply that law to speech alone.
Id.
, at 27–28.
At bottom, Colorado and the dissent fundamentally mis-
conceive this Court's speech-incident-to-conduct precedents.
In these cases, the question is not whether a law mostly ad-
dresses conduct and only sometimes sweeps in speech. In-
stead, the focus lies on two entirely different questions:
whether the law in question restricts speech only because it
is integrally related to unlawful conduct—or whether the law
restricts expressive conduct only for reasons unrelated to its
content. Illustrative of the frst category, this Court has
held that strict scrutiny does not apply to regulations aimed
at speech promoting the sale of contraband because such
speech is often bound up with traditional criminal conduct.
United States v. Williams, 553 U. S. 285, 297–298 (2008); see
also Giboney v. Empire Storage & Ice Co., 336 U. S. 490, 502
(1949); Brief for Eugene Volokh as Amicus Curiae 3–11. Il-
lustrative of the second category, “an ordinance against out-
door fres” would not require a court to apply strict scrutiny
even if it prohibited burning a fag in protest, because the
law forbids conduct without regard to the message it may
convey. Sorrell v. IMS Health Inc., 564 U. S. 552, 567 (2011).
Colorado's law does not regulate speech incident to con-
duct under either test. The State does not dictate what Ms.
Chiles may say because her speech bears a close causal con-
nection to some separately unlawful conduct like a tradi-
tional crime. Rather, Ms. Chiles seeks to speak with inter-
ested clients about steps they might take to change
unwanted behaviors, expressions, or attractions related to
sexual orientation or gender identity—conduct Colorado it-
self does not dispute those clients (or anyone else) may law-
fully undertake. Cf. Tr. of Oral Arg. 58 (conceding that “life
coaches” and other non-licensees can lawfully convey the ad-
vice Ms. Chiles seeks to offer). Nor does Colorado seek to
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650 CHILES
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tent, like a ban on outdoor fres that happens to sweep in
fag
burning. Instead, the State's law trains directly on the
content of her speech and permits her to express some view-
points but not others. Colorado does not regulate speech
i ncident to conduc t; it reg u lates “speech as speech. ”
NIFLA, 585 U. S., at 770.
C
Perhaps sensing that this Court's existing precedents offer
it little support, Colorado ultimately pivots, urging us to re-
shape our doctrine. In doing so, the State begins by point-
ing again to NIFLA. There, recall, the Court observed that
our cases have identifed “two circumstances” in which
speech by professionals may warrant “diminished” First
Amendment protection: when a law seeks to compel disclo-
sure of factual, noncontroversial information in commercial
speech; and when a law regulates speech only incidentally to
conduct. Id., at 767–768 (internal quotation marks omitted).
Still, Colorado emphasizes, NIFLA left open the possibility
that a future party might present “persuasive evidence . . .
of a long (if heretofore unrecognized) tradition” of content
regulation regarding additional categories of professional (or
other) speech that might likewise warrant only “diminished”
First Amendment protection. Id., at 767 (internal quotation
marks omitted); see also United States v. Stevens, 559 U. S.
460, 472 (2010).
Seeking to take up this challenge, Colorado contends that
its law falls within a long tradition of permissible content
regulation. It's a line of argument that comes with a daunt-
ing burden. Under our precedents, the State must present
“persuasive” historical evidence in order to overcome our
“especia[l]” “reluctan[ce] to mark off new categories of
speech for diminished constitutional protection.” NIFLA,
585 U. S., at 767 (internal quotation marks omitted). Still,
Colorado insists, it can carry that burden in this case because
States have traditionally enjoyed wide latitude to proscribe
“substandard care” even when that involves regulating the
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content of speech. Brief for Respondents 16. As evidence,
Colorado
points to the history of state laws licensing the
practice of medicine, regulating informed consent, and per-
mitting tort suits for medical malpractice. Id., at 23–36.
The dissent pursues the same point citing the same authori-
ties. See post, at 667–669, 683–689, 692 (opinion of Jackson,
J.) (suggesting that States may ban “substandard care” pro-
vided “via speech” in light of licensing, informed consent, and
malpractice laws).
This argument stumbles out of the gate, for it proceeds at
far too high a level of generality. From three specifc sets
of laws, Colorado and the dissent ask us to recognize a cav-
ernous “First Amendment Free Zone,” Stevens, 559 U. S., at
469 (internal quotation marks omitted), one in which States
may censor almost any speech they consider “substandard
care.” It is, once more, an approach our precedents al-
ready foreclose.
Consider a couple examples. In Alvarez, the federal gov-
ernment pointed to specifc, historical laws proscribing fraud
and defamation and asked us to extrapolate from them a
much broader rule allowing it to enforce content-based re-
strictions on any “false statements.” In NIFLA, California
suggested that informed-consent laws and our speech-
incident-to-conduct doctrine might be cobbled together to
sustain the recognition of a feld of “professional speech” sub-
ject only to rational-basis review. We rejected both efforts,
stressing instead that discrete traditions of content-based
regulations cannot be aggregated together to sustain some
new and broader category of lesser-protected speech. Al-
varez, 567 U. S., at 718–722 (plurality opinion); id., at 736
(Breyer, J., concurring in judgment); NIFLA, 585 U. S., at
767–768; see also Button, 371 U. S., at 439–440 (distinguish-
ing State's law from laws proscribing accepted “common-law
offenses”); Florida Star v. B. J. F., 491 U. S. 524, 539 (1989)
(similar). And Colorado's similar effort can succeed no more
than others like it have in the past.
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Beyond that problem lies another. Taking each of the
three
traditions Colorado and the dissent invoke on its own
terms—as we must—none delivers the support they suppose.
Start with Colorado's suggestion, endorsed by the dissent,
that the State's statute represents nothing more than a tra-
ditional law licensing the practice of medicine. See Brief for
Respondents 27–28; post, at 683–685 (opinion of Jackson, J.).
We cannot agree for at least two reasons. First, the State
has not presented persuasive evidence that its law is part of
a historical tradition. When assessed at the level of gener-
ality our precedents demand, what Colorado describes turns
out to be a relatively recent innovation. Indeed, the
briefng before us suggests that the very frst state “coun-
selor-licensure bill” was adopted only in 1976. National
Academies, Institute of Medicine, Provision of Mental Health
Counseling Services Under TRICARE 94 (2010); D. Berg-
man, The Role of Government and Lobbying in the Creation
of a Health Profession: The Legal Foundations of Counseling,
91 J. Counseling & Development 61 (2013) (Bergman); see
also Brief for Petitioner 42. And that is far from the sort
of “persuasive evidence” of a historically grounded practice
our precedents require. NIFLA, 585 U. S., at 767 (internal
quotation marks omitted).
Second, licensing laws have traditionally addressed what
qualifcations an individual must possess before practicing a
particular profession. See Bergman 62 (licensing laws gen-
erally “establis[h] minimum standards of preparation and en-
sur[e] the professional is qualifed”); R. Kry, The “Watchman
for Truth”: Professional Licensing and the First Amend-
ment, 23 Seattle U. L. Rev. 885, 887 (2000) (a “licensure
scheme typically sets out certain requirements that the pro-
fessional must fulfll before practicing ”). And whatever tra-
ditional interest a State may have in ensuring a professional
possesses a particular set of qualifcations, that interest does
not automatically entail a right to dictate a professional's
point of view. NIFLA, 585 U. S., at 773.
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Opinion of the Court
Turn now to Colorado's effort, again echoed by the dissent,
to
compare its statute to informed-consent laws. See Brief
for Respondents 34–36; post, at 667–669 (opinion of Jackson,
J.). Those laws generally require a doctor to inform a pa-
tient about “the nature of [a proposed] procedure” and its
attendant “risks.” NIFLA, 585 U. S., at 769–770 (internal
quotation marks omitted). As such, informedconsent laws
do not usually trigger strict scrutiny because they regulate
speech only incident to separate physical conduct that would,
“without [the] patient's consent,” amount to “an assault.”
Id., at 770 (internal quotation marks omitted). Usually, too,
informed-consent laws require practitioners to disclose only
factual and uncontroversial information. See id., at 769–
770. But all that is a far cry from how Colorado's law oper-
ates here. As applied to Ms. Chiles, the State seeks neither
to regulate her speech incident to any conduct, nor does it
seek to compel disclosure of factual and uncontroversial in-
formation. Instead, it seeks to silence a viewpoint she
wishes to express.
Colorado and the dissent close by asking us to analogize
the State's law to traditional tort malpractice claims. See
Brief for Respondents 25–26; post, at 685–686 (opinion of Jack-
son, J.). But here again the differences are impossible to
ignore. In a traditional malpractice action, liability attaches
only if the plaintiff shows, among other things, that he has
suffered an injury caused by the defendant's breach of the
applicable duty of care. See, e. g., Day v. Johnson, 255 P. 3d
1064, 1068–1069 (Colo. 2011). Those kinds of “[e]xacting
proof requirements,” we have observed, may “provide suff-
cient breathing room for protected speech.” Illinois ex rel.
Madigan v. Telemarketing Associates, Inc., 538 U. S. 600,
620 (2003). Yet Colorado's law contains nothing like them,
instead threatening individuals with fnes, probation, and the
loss of their licenses simply for expressing a particular view.
See §§ 12–245–202(3.5), 12–245–224(1)(t), 12–245–225. Nor
does Colorado's law allow clients to consent to practices that
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depart from the prevailing standard of care, while malprac-
tice
law sometimes does. See Restatement (Third) of Torts:
Medical Malpractice § 11 (2024); Schneider v. Revici, 817
F. 2d 987, 995 (CA2 1987).
Consider, too, where the State and dissent's logic leads.
Not long ago, many medical experts and organizations, in-
cluding the American Psychiatric Association, considered ho-
mosexuality a mental disorder. See American Psychiatric
Association, Diagnostic and Statistical Manual of Mental Dis-
orders 38–39 (1952); cf. American Psychiatric Association,
Position Statement on Homosexuality and Civil Rights, 131
Am. J. Psychiatry 497 (1974). On the view Colorado and the
dissent advance, a law adopted during that era prohibiting
counselors from engaging in the “substandard care” of af-
frming their clients' homosexuality would have been subject
to only rational-basis or intermediate-scrutiny review—and
likely upheld. See 116 F. 4th, at 1237–1238 (Hartz, J., dis-
senting). Today, tomorrow, and forever, too, any profes-
sional speech that deviates from “current beliefs about the
safety and effcacy of various medical treatments” could be
silenced with relative ease. Post, at 681 (opinion of Jack-
son, J.). It is a consequence Colorado freely acknowledges.
Tr. of Oral Arg. 61–63. And one the dissent embraces.
Post, at 681–683, and n. 9 (opinion of Jackson, J.). So what
if that kind of refexive deference to currently prevailing pro-
fessional views may not always end well? Cf. Buck v. Bell,
274 U. S. 200, 205–207 (1927).
Fortunately, that is not the world the First Amendment
envisions for us. Licensed professionals “have a host of
good-faith disagreements” about the “prudence” and “ethics”
of various practices in their felds. NIFLA, 585 U. S., at 772.
Medical consensus, too, is not static; it evolves and always
has. A prevailing standard of care may refect what most
practitioners believe today, but it cannot mark the outer
boundary of what they may say tomorrow. Far from a test

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655
Kagan, J., concurring
of professional consensus, the First Amendment rests in-
stead
on a simple truth: “[T]he people lose” whenever the
government transforms prevailing opinion into enforced con-
formity. Ibid.
III
We do not doubt that the question “how best to help mi-
nors” struggling with issues of gender identity or sexual ori-
entation is presently a subject of “ferce public debate.”
Tingley v. Ferguson, 601 U. S. 955, 956 (2023) (Thomas, J.,
dissenting from denial of certiorari). But Colorado's law ad-
dressing conversion therapy does not just ban physical inter-
ventions. In cases like this, it censors speech based on
viewpoint. Colorado may regard its policy as essential to
public health and safety. Certainly, censorious governments
throughout history have believed the same. But the First
Amendment stands as a shield against any effort to enforce
orthodoxy in thought or speech in this country. It refects
instead a judgment that every American possesses an in-
alienable right to think and speak freely, and a faith in the
free marketplace of ideas as the best means for discovering
truth. However well-intentioned, any law that suppresses
speech based on viewpoint represents an “egregious” assault
on both of those commitments. Rosenberger, 515 U. S.,
at 829.
The judgment of the Tenth Circuit is reversed, and the
case remanded for further proceedings consistent with this
opinion.
It is so ordered.
Justice Kagan, with whom Justice Sotomayor joins,
concurring.
The Court today decides that the Colorado law challenged
here, as applied to talk therapy, conficts with core First
Amendment principles because it regulates speech based on
viewpoint. See ante, at 655. I agree. I write only to note
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that if Colorado had instead enacted a content-based but
v
iewpoint-neutral law, it would raise a different and more
diffcult question.
As the Court states, governments must “nearly always”
abstain from adopting viewpoint-based restrictions. Ante,
at 641. Those laws represent a particularly “egregious
form” of content-based regulation, implicating First Amend-
ment concerns to the highest possible degree. Ibid.; see
Iancu v. Brunetti, 588 U. S. 388, 393 (2019). A law drawing
a line based on the “ideology” of the speaker—disadvantag-
ing one view and advantaging another—skews the market-
place of ideas our society depends on to discover truth. Ro-
senberger v. Rector and Visitors of Univ. of Va., 515 U. S.
819, 829 (1995). And such a law suggests an impermissible
motive—that the government is regulating speech because
of its own “hostility” toward the targeted messages. R. A. V.
v. St. Paul, 505 U. S. 377, 386 (1992). If the First Amend-
ment prohibits anything, it is the “offcial suppression of
ideas.” Id., at 390; see Reed v. Town of Gilbert, 576 U. S.
155, 181–183 (2015) (Kagan, J., concurring in judgment). Be-
cause viewpoint-based laws always raise that specter, they
are the most suspect of all speech regulations. So much so
that this Court has refused to permit viewpoint discrimina-
tion even within unprotected categories of speech, like fght-
ing words or obscenity. See R. A. V., 505 U. S., at 384–390.
Colorado's law, as applied to talk therapy, regulates based
on viewpoint, for the reasons the Court gives. See ante,
at 645–646. The law forbids a counselor to provide therapy
designed to “change [a minor's] sexual orientation or gender
identity.” Colo. Rev. Stat. § 12–245–202(3.5)(a) (2025); see
§ 12–245–224(1)(t)(V). At the same time, the law specifcally
allows a counselor to offer therapy expressing “[a]cceptance,
support,” and other affrmation of the minor's “identity ex-
ploration.” § 12–245–202(3.5)(b)(I)–(II). So, for example,
the law prevents a therapist from saying she can help a
minor change his same-sex orientation, but permits her to
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Kagan, J., concurring
say that such a goal is impossible and so she will help him
accept
his gay identity. Colorado does not dispute that
point. See Tr. of Oral Arg. 78. Nor does it dispute that
under normal First Amendment principles, that difference
constitutes viewpoint discrimination. See ibid. Indeed,
the case is textbook. The law “distinguishes between two
opposed sets of ideas”—the one resisting, the other refect-
ing, the State's own view of how to speak with minors about
sexual orientation and gender identity. Iancu, 588 U. S., at
394. Or said just a bit differently, the law draws a line based
on the speaker's “opinion or perspective,” and thus enables
“speech on only one side”—the State's preferred side—of an
ideologically charged issue. Rosenberger, 515 U. S., at 829;
McCullen v. Coakley, 573 U. S. 464, 485 (2014).
Of course, it does not matter what the State's preferred
side is. Consider a hypothetical law that is the mirror
image of Colorado's. Instead of barring talk therapy de-
signed to change a minor's sexual orientation or gender iden-
tity, this law bars therapy affrming those things. As Ms.
Chiles readily acknowledges, the First Amendment would
apply in the identical way. See Tr. of Oral Arg. 25–26; see
also id., at 37–38 (United States as amicus curiae agreeing).
Once again, because the State has suppressed one side of a
debate, while aiding the other, the constitutional issue is
straightforward.
It would, however, be less so if the law under review was
content based but viewpoint neutral. Such content-based
laws, as the Court explains, trigger strict scrutiny “[a]s a
general rule.” Ante, at 640. But our precedents respecting
those laws recognize complexity and nuance. We apply our
most demanding standard when there is any “realistic possi-
bility that offcial suppression of ideas is afoot”—when, that
is, a (merely) content-based law may reasonably be thought
to pose the dangers that viewpoint-based laws always do.
Davenport v. Washington Ed. Assn., 551 U. S. 177, 189
(2007); see supra, at 656. But when that is not the case—
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when a law, though based on content, raises no real concern
that
the government is censoring disfavored ideas—then we
have not infrequently “relax[ed] our guard.” Reed, 576
U. S., at 183 (opinion of Kagan, J.); see Davenport, 551 U. S.,
at 188 (noting the “numerous situations in which [the] risk”
of a content-based law “driv[ing] certain ideas or viewpoints
from the marketplace” is “attenuated” or “inconsequential,
so that strict scrutiny is unwarranted”). Just two Terms
ago, for example, the Court declined to apply strict scrutiny
to a content-based but viewpoint-neutral trademark restric-
tion. See Vidal v. Elster, 602 U. S. 286, 295 (2024); id., at
312 (Barrett, J., concurring in part); id., at 329–330 (Soto-
mayor, J., concurring in judgment). In the trademark con-
text, as in some others, experience and reason alike showed
“no signifcant danger of idea or viewpoint” bias. R. A. V.,
505 U. S., at 388.
The same may wel l be tr ue of content-based but
viewpoint-neutral laws regulating speech in doctors' and
counselors' offces.* Medical care typically involves speech,
so the regulation of medical care (which is, of course, perva-
sive) may involve speech restrictions. And those restric-
tions will generally refer to the speech's content. Cf. Reed,
576 U. S., at 177 (Breyer, J., concurring in judgment) (noting
that “[r]egulatory programs” addressing speech “inevitably
involve content discrimination”). But laws of that kind may
not pose the risk of censorship—of “offcial suppression of
ideas”—that appropriately triggers our most rigorous re-
view. R. A. V., 505 U. S., at 390. And that means the “dif-
*Justice Jackson's dissenting opinion claims that this is a small, or
even nonexistent, category. See post, at 679–680, n. 8. But even her own
opinion, when listing laws supposedly put at risk today, offers quite a few
examples. See post, at 689–690, and n. 13. Her view to the contrary
rests on reimagining—and in that way collapsing—the well-settled distinc-
tion between viewpoint-based and other content-based speech restrictions.
See, e. g., Vidal v. Elster, 602 U. S. 286, 292–293 (2024) (explaining the
difference).
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Jackson, J., dissenting
ference between viewpoint-based and viewpoint-neutral con-
tent
discrimination” in the health-care context could prove
“decisive.” Vidal, 602 U. S., at 330 (opinion of Sotomayor,
J.). Fuller consideration of that question, though, can wait
for another day. We need not here decide how to assess
viewpoint-neutral laws regulating health providers' expres-
sion because, as the Court holds, Colorado's is not one.
Justice Jackson, dissenting.
“[T]here is no right to practice medicine which is not sub-
ordinate to the police power of the States.” Lambert v. Yel-
lowley, 272 U. S. 581, 596 (1926). This was true 100 years
ago, and it should be true today.
Many States have now chosen to exercise their police pow-
ers to ban “conversion therapy” based on the medical profes-
sion's broad consensus that this medical treatment (which
seeks to change a gay or transgender person's sexual orienta-
tion or gender identity) is ineffective and harmful. This
case involves the Colorado Legislature's policy decision to
prohibit licensed medical professionals from offering or pro-
viding conversion therapy to minors in that State.
Petitioner Kaley Chiles is a licensed counselor who works
in the State of Colorado. She does not dispute that conver-
sion therapy can be harmful to minors in certain circum-
stances. Nor does she contest that Colorado has a signif-
cant interest in protecting minors from harm. Chiles
complains nevertheless that, because the particular form of
conversion therapy she wants to offer clients utilizes only
speech, the First Amendment prevents Colorado from pro-
hibiting that treatment. But “[t]he power of government to
regulate the professions is not lost whenever the practice of
a profession entails speech.” Lowe v. SEC, 472 U. S. 181,
228 (1985) (White, J., concurring in result). And “[m]edical
professionals do not, generally speaking, have a right to use
the Constitution as a weapon allowing them rigorously to
control the content of . . . reasonable conditions” that a State
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imposes on licensed healthcare providers for the protection
of
its residents. National Institute of Family and Life Ad-
vocates v. Becerra, 585 U. S. 755, 785 (2018) (Breyer, J.,
dissenting) (NIFLA).
So, I respectfully dissent. Stated simply, the majority has
failed to appreciate the crucial context in which Chiles's con-
stitutional claims have arisen. Chiles is not speaking in the
ether; she is providing therapy to minors as a licensed
healthcare professional. The Tenth Circuit was correct to
observe that “[t]here is a long-established history of states
regulating the healthcare professions.” 116 F. 4th 1178,
1206 (2024). And, until today, the First Amendment has not
blocked their way. For good reason: Under our precedents,
bedrock First Amendment principles have far less salience
when the speakers are medical professionals and their
treatment-related speech is being restricted incidentally to
the State's regulation of the provision of medical care.
No one directly disputes that Colorado has the power to
regulate the medical treatments that state-licensed profes-
sionals provide to patients. Nor is it asserted that, when
doing so, a State always runs afoul of the Constitution. So,
in my view, it cannot also be the case that Colorado's decision
to restrict a dangerous therapy modality that, incidentally,
involves provider speech is presumptively unconstitutional.
In concluding otherwise, the Court's opinion misreads our
precedents, is unprincipled and unworkable, and will eventu-
ally prove untenable for those who rely upon the long-
recognized responsibility of States to regulate the medical
profession for the protection of public health.
I
To properly evaluate the First Amendment claim at issue
in this case, one must frst understand the impetus for Colo-
rado's regulation, what that law requires, and the nature of
the speech it implicates.
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Jackson, J., dissenting
A
Con
version therapy is designed to “convert” a person's
sexual orientation or gender identity, so that the person will
become heterosexual or cisgender. Generally speaking, con-
version therapy began as an attempt to “cure” gay and trans-
gender people of their “nonconforming ” orientations or iden-
tities. Brief for American Psychological Association et al.
as Amici Curiae 13.
Conversion-therapy efforts have historically included
aversive therapeutic modalities. Those ranged from induc-
ing nausea, vomiting, or paralysis in patients or subjecting
them to severe electric shocks to telling patients to snap an
elastic band on their wrists in response to nonconforming
thoughts. Aversive therapies have now fallen out of fash-
ion; nonaversive treatments—primarily, talk therapy—are
currently the predominant form of conversion therapy. All
such therapies seek to encourage patients to change their
behavior in an attempt to “change” their identity.
Over the past few decades, however, the premise of con-
version therapy (in whatever form) has been widely discred-
ited within the medical and scientifc community. Conver-
sion therapy is, at bottom, “based on a view of gender
diversity that runs counter to scientifc consensus.” Sub-
stance Abuse and Mental Health Services Administration
(SAMHSA) Report, 2 App. 570. That is, contrary to the
core beliefs that undergird conversion therapy, a robust pro-
fessional consensus now acknowledges that sexual orienta-
tions and gender identities range widely. And it no longer
regards nonheterosexual orientations or noncisgender identi-
ties as “nonconforming.”
Because people's identities are simply “a part of the nor-
mal spectrum of human diversity,” id., at 535, the medical
community has determined that efforts to change a patient's
sexual orientation or gender identity will necessarily be inef-
fective. The American Psychological Association (APA), for
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example, has found “no empirical evidence that providing
any
type of therapy in childhood can alter adult same-sex
sexual orientation.” APA Report, 1 App. 360. And “[n]o
research has been published in the peer-reviewed literature
that demonstrates the effcacy of conversion therapy efforts
with gender minority youth, nor any benefts of such inter-
ventions to children and their families.” SAMHSA Report,
2 App. 569.
Not only is conversion therapy ineffective, former partici-
pants of conversion therapy report that it causes lasting psy-
chological harm. Gay and transgender children who under-
went nonaversive conversion therapy say they were taught
to feel shame and self-hatred. See Brief for Conversion
Therapy Survivor Network et al. as Amici Curiae 11–14.
And survivors of conversion therapy continue to suffer from
PTSD, anxiety, and suicidal ideation. Id., at 19–22. As one
survivor put it, conversion therapy “ `came close to killing
me.' ” Id., at 17.
1
The scientifc literature confrms what anecdotal experi-
ences suggest: Conversion therapy has harmed patients, par-
ticularly minors. The APA found that “the reported nega-
1
Consider a specifc example: An amicus who received conversion
therapy as a child, Mathew Shurka, was told that his sexual orientation
was a disorder either rooted in childhood trauma or stemming from an
overbearing mother or absent father. Brief for Mathew Shurka as Ami-
cus Curiae 6. In the course of this therapy, Mathew's therapist said that
being gay was a mental illness that could be cured and that, unless he was
cured, he could never live a happy and fulflled life. Id., at 3. Mathew's
conversion therapists eventually hypothesized that his mother was the
source of his sexual orientation and instructed him to avoid speaking with
her. Id., at 8. For three years, he had barely any contact with his
mother. Ibid. The years of conversion therapy brought Mathew nothing
but increased isolation from his family, worsening depression, and suicidal
ideation. Id., at 11. Thus, as Mathew's experience illustrates, the harm
from conversion therapy extends to the patient's family. See also Brief
for Parents of Conversion-Therapy Participants et al. as Amici Curiae 9–
19 (describing the impact of conversion therapy on amici's families, includ-
ing the loss of loved ones to suicide).
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Jackson, J., dissenting
tive social and emotional consequences [of conversion
therapy
] include self-reports of anger, anxiety, confusion, de-
pression, grief, guilt, hopelessness, deteriorated relation-
ships with family, loss of social support, loss of faith, poor
self-image, social isolation, intimacy diffculties, intrusive im-
agery, suicidal ideation, self-hatred, and sexual dysfunction.”
APA Report, 1 App. 253–254. Even for those study partici-
pants who reported positive effects initially, many described
experiencing the negative effects later. Id., at 254. More-
over, studies show that children often feel the effects of the
shame and stigma from conversion therapy even more viv-
idly than adults due to their “increased emotional vulnerabil-
ity and less developed capacity to cope effectively with the
harm of discrimination.” Glassgold Decl., 1 App. 53–54,
¶ 50.
Ultimately, scientifc evidence supports the conclusion that
the anticipated harms from conversion therapy are twofold.
First, conversion therapy stigmatizes the patient, telling
them that their gender identity or sexual orientation is
something to be fxed, rather than accepted. This rejection
can lead to shame and guilt, which in turn can cause long-
term emotional distress. Second, conversion therapy sets
patients up to fail by giving them an unattainable goal.
Some patients have described that experience of failure “as
a signifcant cause of emotional and spiritual distress and
negative self-image.” Id., at 63, ¶ 66.
B
In 2019, Colorado joined 25 other States in banning the
practice of conversion therapy for minors. Colorado's law—
titled the Minor Conversion Therapy Law (MCTL)—prohib-
its licensed healthcare professionals from practicing conver-
sion therapy with children. It defnes conversion therapy
as “any practice or treatment” that “attempts or purports to
change an individual's sexual orientation or gender identity,
including efforts to change behaviors or gender expressions
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or to eliminate or reduce sexual or romantic attraction or
feel
ings toward individuals of the same sex.” Colo. Rev.
Stat. § 12–245–202(3.5)(a) (2025).
2
Not all therapeutic discussions of sexuality and gender
identity are prohibited by the MCTL. The law allows
“practices or treatments that provide:
“(I) Acceptance, support, and understanding for the
facilitation of an individual's coping, social support, and
identity exploration and development, including sexual-
orientation-neutral interventions to prevent or address
unlawful conduct or unsafe sexual practices, as long as
the counseling does not seek to change sexual orienta-
tion or gender identity; or
“(II) Assistance to a person undergoing gender tran-
sition.” § 12–245–202(3.5)(b).
The Colorado Legislature made these allowances after
crediting witness testimony and the professional consensus
about conversion therapy—namely, that it is harmful, and
that the preferred treatment for minors relating to their sex-
ual orientation and gender identity is affrming care (i. e.,
medical care that helps minors focus on acceptance, support,
coping, and identity exploration and development). Prohibit
Conversion Therapy for a Minor: Hearing on H. B. 19–1129
before the House Committee on Public Health Care & Hum.
Servs., 2019 Leg., 72d Gen. Sess. (Colo., Feb. 13, 2019).
C
Chiles insists that, although she is a counselor licensed by
Colorado, she has a constitutional right to fout Colorado's
2
The MCTL primarily applies to licensed healthcare professionals; such
professionals are already subject to a number of other restrictions on their
professional practice. Most relevant here, under Colorado law, licensed
therapists must provide therapy that is consistent with the standard of
care, defned as “the standards of practice generally recognized by state
and national associations of practitioners in the feld of the person's profes-
sional discipline.” Colo. Rev. Stat. § 12–245–224(1)(g)(I).
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Jackson, J., dissenting
statute and the standard of care it incorporates if a client
asks
her to do so. Never mind that medical professionals—
including counselors like Chiles—are generally bound to fol-
low medical standards and state licensing requirements
when they provide medical care to patients. Chiles wants
to offer patients conversion therapy despite the MCTL and
the medical consensus it refects. So she has invoked the
First Amendment, arguing that, because talk therapy is
speech, no State can impose treatment standards like the
MCTL on licensed talk therapists without frst satisfying
heightened scrutiny.
As applied to Chiles, the MCTL treats the talk-therapy
form of conversion therapy as a prohibited medical treat-
ment. But Chiles is free to express her opinion about the
effcacy of conversion therapy or her disagreement with Col-
orado's conclusion that such therapy is harmful to minors.
Colorado's law does not target or prohibit the expression of
such views by anyone in any form—including by licensed
healthcare providers in discussions with patients and their
families. All that Colorado's law proscribes is the provision
of such therapy to minors. This means that, while Chiles
can freely promote conversion therapy and vociferously
decry the State's prohibition, she cannot practice that ther-
apy without being subject to professional discipline under
Colorado law.
II
I begin my analysis with a simple observation: Our First
Amendment jurisprudence does not treat speech as existing
in a vacuum. Instead, how the First Amendment applies to
a State's power to regulate speech depends upon the context
in which the regulation of speech occurs. See, e. g., Vidal v.
Elster, 602 U. S. 286 (2024) (trademark context); Tinker v.
Des Moines Independent Community School Dist., 393 U. S.
503 (1969) (school context). We have not mechanically held
that the First Amendment protects all communicative con-
tent; rather, we have evaluated First Amendment claims in
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a nuanced way, sensitive to both core principles and the spe-
ci
fc circumstances under which the claim arises. See, e. g.,
Virginia Bd. of Pharmacy v. Virginia Citizens Consumer
Council, Inc., 425 U. S. 748, 758, 762–770 (1976) (considering
First Amendment principles in the commercial speech
context).
In my view, then, it matters for First Amendment pur-
poses that the MCTL restricts treatment-related speech
uttered by medical professionals only as part of a larger reg-
ulatory scheme aimed at ensuring that providers tender
high-quality medical care to patients.
In Part II–A, I explain that this way of conceptualizing
the question before us is not novel—we have long understood
that States have the power to regulate medical professionals.
And our precedents demonstrate that, when a healthcare
provider's speech is incidentally restricted as part of a state-
law scheme regulating the provision of medical treatments,
the heightened scrutiny we refexively apply in other situa-
tions is not warranted. In Part II–B, I show that First
Amendment principles are not offended when lesser scrutiny
is applied to a state law regulating medical treatments in a
manner that incidentally restricts a provider's professional
medical speech.
A
1
A case that we decided in 2018—NIFLA—shows us the
way to determine the appropriate level of constitutional scru-
tiny here. 585 U. S. 755. In that case, we began by explain-
ing that “[s]peech is not unprotected merely because it is
uttered by `professionals.' ” Id., at 767; see also ante, at 642–
643, 646–647. But, critically, we also acknowledged that the
Court has afforded less protection for professional speech in
two circumstances—one of which occurs when a State “regu-
late[s] professional conduct, even though that conduct inci-
dentally involves speech.” NIFLA, 585 U. S., at 768; see
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ante, at 643. This acknowledgement was grounded in an al-
ready
well-established principle: “[T]he First Amendment
does not prevent restrictions directed at . . . conduct from
imposing incidental burdens on speech.” Sorrell v. IMS
Health Inc., 564 U. S. 552, 567 (2011).
To further explain the contours of this presumptively per-
missible speech restriction, NIFLA cited Planned Parent-
hood of Southeastern Pa. v. Casey, 505 U. S. 833 (1992). In
Casey, the Court assessed “an asserted First Amendment
right of a physician not to provide information about the
risks of abortion, and childbirth, in a manner mandated by
the State.” Id., at 884 ( joint opinion of O'Connor, Kennedy,
and Souter, JJ.). More specifcally, Casey involved a chal-
lenge to a Pennsylvania law requiring that “a doctor give a
woman certain information as part of obtaining her consent
to an abortion.” Ibid.
3
We held that Pennsylvania's
informed-consent mandate did not violate the First Amend-
ment. “To be sure, the physician's First Amendment rights
not to speak [were] implicated” by Pennsylvania's law. Ibid.
But we emphasized that those rights were implicated “only
as part of the practice of medicine, subject to reasonable
licensing and regulation by the State.” Ibid. (emphasis
added). Thus, there was “no constitutional infrmity in the
requirement that the physician provide the information man-
dated by the State.” Ibid.
In NIFLA, we reaffrmed the principle from Casey that
the First Amendment inquiry requires consideration of
whether the regulated speech was made during the provision
of medical care. NIFLA involved a challenge to a California
law that required certain crisis pregnancy centers to post
notices in their waiting rooms informing low-income patients
3
The First Amendment challenge to Pennsylvania's law in Casey was
effectively the fipside of the one Chiles brings here: While the doctors in
Casey complained that Pennsylvania was forcing them to speak when they
did not want to, Chiles asserts that Colorado is preventing her from saying
what she wants to say.
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that California paid for qualifying abortions. 585 U. S., at
762
–763. We asked whether, on the one hand, this law was
regulating the clinics' speech qua speech, or whether, on the
other, the notice requirement was actually regulating the
clinics' professional conduct and only incidentally restricting
speech. If the latter, the NIFLA Court explained, Califor-
nia's notice requirement would ft into the category of cases
that Casey illustrated; namely, those in which “this Court
has upheld regulations of professional conduct that inciden-
tally burden speech.” 585 U. S., at 769.
Relying in part on Casey's analytical framework, the
NIFLA Court held that California's law regulated “speech
as speech.” 585 U. S., at 770. We explained this conclusion
by contrasting the Pennsylvania regulation at issue in Casey:
While the notice requirement in Casey restricted doctors'
speech, it did so “only `as part of the practice of medicine.' ”
585 U. S., at 770. The notice requirement at issue in
NIFLA, by contrast, was “not an informed-consent require-
ment or any other regulation of professional conduct.” Ibid.
“In fact,” California's notice was “not tied to a procedure at
all. It applie[d] to all interactions between a covered facil-
ity and its clients, regardless of whether a medical procedure
[was] ever sought, offered, or performed.” Ibid. (emphasis
added). So, we reasoned, unlike Pennsylvania's informed-
consent requirement in Casey, California's notice mandate
warranted heightened scr utiny because it “reg u late[d]
speech as speech.” 585 U. S., at 770.
The takeaway from NIFLA is that Casey applied a lower
level of scrutiny because the law in Casey restricted speech
uttered in the course of—and as a part of—providing profes-
sional medical care. By contrast, the notice requirement in
NIFLA was not “tied to a procedure at all” and was there-
fore meaningfully different: That law restricted “speech as
speech.” 585 U. S., at 770. Thus, the key distinction, as the
NIFLA Court saw it, was whether the challenged law was a
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Jackson, J., dissenting
regulation of speech as such or a regulation of “professional
conduc
t that incidentally burden[ed] speech.” Id., at 769.
2
Given all this, one might think today's majority would
make more of an effort to explain why the MCTL does not
likewise qualify as a regulation of “professional conduct that
incidentally burden[s] speech.” Ibid.; see ante, at 646–650.
Such an inquiry would entail evaluating whether the MCTL's
restriction on Chiles's therapy only “incidentally” restricts
Chiles's speech by virtue of the fact that the medical care
she provides is delivered orally. It would also require ac-
knowledging that the MCTL's restriction on Chiles is plainly
“tied to [the provision of] a [medical] procedure,” NIFLA,
585 U. S., at 770—one that, but for Colorado's law, a licensed
counselor like Chiles might offer to minors.
In my view, it is obvious that the MCTL is regulating pro-
fessional conduct insofar as it prohibits providing a particu-
lar therapy; the aim of the statute is not suppressing speech.
Indeed, Chiles's claim that her (otherwise protected) speech
is being swept up by Colorado's (otherwise valid) treatment
prohibition proves that very point. This set of circum-
stances seems to ft NIFLA's idea of permissible state “regu-
lation of professional conduct” that “incidentally burdens
speech” to a “T.”
Yet, the majority strangely suggests otherwise with the
opinion it hands down today. Ante, at 646–650. The major-
ity does this primarily by eschewing serious engagement
with the interaction between NIFLA and Casey. Its work-
around seems to be: The First Amendment applies full bore
here because Chiles's speech is being impacted; after all, she
is a talk therapy provider. Ante, at 644–650. But when
NIFLA's teachings are properly understood, this comeback is
no answer. Yes, Chiles happens to be talking when she's pro-
viding therapy to patients, but the MCTL regulates the provi-
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sion of medical treatments by licensed medical professionals,
wh
ich States are fully empowered to do. That Chiles's kind
of medical care involves talk therapy is, in NIFLA's words,
merely “incidenta[l].” 585 U. S., at 769.
I am the frst to admit that, as applied to talk therapists
like Chiles, the MCTL restricts speech—I do not argue that
this law really just limits Chiles's professional conduct. See
ante, at 644–645, 647–648 (characterizing Colorado's argu-
ment). Similarly, I do not maintain that, because this law
primarily regulates talk-therapists' professional conduct, it
should not be conceived of as a speech restriction. See ante,
at 649. I agree with the majority that, in cases like Cohen
v. California, 403 U. S. 15 (1971), we frmly rejected a State's
attempt to suppress free speech by calling the restricted ex-
pression “conduct.” Ante, at 648–649. But, here, the ob-
servation that the MCTL indeed restricts Chiles's “speech”
(not reformulated as conduct) just raises the question that
this case presents: Whether the MCTL is restricting Chiles's
speech “incidentally” to its regulation of medical profession-
als' treatment-related conduct, such that the law warrants
less scrutiny under the First Amendment than a law that re-
stricts her speech “as speech.” NIFLA, 585 U. S., at 769–770.
The majority's failure to acknowledge that this is the ac-
tual issue here—not just whether Chiles's “speech” or “con-
duct” is being restricted, but what the State is doing—
ignores what has always been true under our precedents.
The real lesson of NIFLA's discussion of Casey is this: When
a healthcare professional's speech is not being targeted “as
speech” (because it conveys an idea) but is instead “inciden-
tally” restricted due to a State's otherwise legitimate regula-
tion of the medical treatments being offered to patients,
heightened scrutiny is not warranted. 585 U. S., at 769–770;
Casey, 505 U. S., at 884 ( joint opinion of O'Connor, Kennedy,
and Souter, JJ.).
3
NIFLA's focus on a State's regulation of medical treat-
ments also undermines the position the United States has
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Jackson, J., dissenting
taken on today's First Amendment question. The United
St
ates, joining this case as amicus curiae, insists, in essence,
that when the NIFLA Court acknowledged that States can
regulate professional conduct while “incidentally” restrict-
ing speech, it was blessing only two circumstances: (1) where
the speech that is being restricted is inextricably tied to an
act of the speaker (so, speech-only therapists are never in-
cluded), or (2) where speech is being regulated in a manner
entirely unrelated to its content. Brief for United States as
Amicus Curiae 17–21; see ante, at 643, 647–649. But, under
NIFLA's reasoning, that cannot be so—at least not logically.
With respect to the frst category, the United States mis-
takenly swaps “integral” (i. e., whether the restricted speech
is bound up with the regulated conduct) for “incidental”—
but these are two completely different concepts.
4
Given
NIFLA's focus on the “incidental” nature of the challenged
speech restriction, the State's objective is the actual fulcrum:
We ask whether, on the one hand, the State's law is restrict-
ing the provider's speech “incidentally” (meaning in the
4
Under the reading the United States advocates, the line between per-
missible and impermissible state regulation seems to turn on the relation-
ship between the restricted speech and a physical act of the speaker. See
Tr. of Oral Arg. 35–36. So, the argument goes, the First Amendment
allows state regulation if the speech restriction is “incidental” to a physi-
cal act of the healthcare provider, but prohibits it if there is no physical
act for the speech to be “incidental” to because the provider treats pa-
tients solely with speech. See id., at 35 (“[T]his Court hasn't drawn a
particularly clear line about when speech is close enough to conduct to be
viewed as incidental, but, here, again, this is an easy case because there
is no conduct”); id., at 33 (emphasizing that, because Chiles is a talk thera-
pist, “[t]here's no separate non-speech conduct being regulated here”); see
also Brief for United States as Amicus Curiae 24, 26 (noting that “regula-
tions of the mental-health profession are less likely to qualify as `inciden-
tal' burdens on speech . . . because much mental-health treatment is con-
ducted using only speech”). This logic rests upon the integral nature of
the speech to the conduct that is being regulated. But that is different
from—and says nothing about—whether the speech is being regulated “in-
cidentally,” which is the line that NIFLA draws. See National Institute
of Family and Life Advocates v. Becerra, 585 U. S. 755, 769–770 (2018).
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course of the State's pursuit of its primary objective of regu-
lati
ng the provision of medical care), or whether, on the
other, the State's law is restricting her speech “as speech”
(primarily to suppress its message or expressive content).
585 U. S., at 769–770. The appropriate scrutiny level logi-
cally follows: Incidentally restricting speech needs less scru-
tiny because we view the State as generally regulating the
provision of medical care, while restricting “speech as
speech” receives heightened scrutiny because the State is
aiming at professional speech qua speech.
The second “speech incident to conduct” category the
United States advances—whether the restriction on speech
is unrelated to its content—is also fatally fawed. It ignores
what NIFLA plainly recognizes: that States can regulate the
medical treatments healthcare professionals provide to pa-
tients without running afoul of the First Amendment, even
if the regulation applies to and restricts speech based on
its content. 585 U. S., at 769–770. In other words, what
mattered to NIFLA's analysis was not that the regulation
was content-based, but instead that the speech was being
restricted incidentally.
So it is here. Talk therapy is a medical treatment. 116
F. 4th, at 1206, 1208–1210. So, why wouldn't such speech-
based medical treatments be subject to reasonable state reg-
ulation like any other kind of medical care? The United
States and the majority just insist that a law that undertakes
to regulate speech-based medical treatments is presump-
tively unconstitutional because the treatment is being
administered solely through speech. But that reasoning
is maddeningly circular, and it is based on happenstance,
not logic. Even more important, it is not the rationale upon
which NIFLA's analysis relies. To the contrary, with
its description of Casey, NIFLA recognizes precisely the
opposite—a State can regulate professionals' treatment-
related conduct even if doing so impacts treatment-related
speech.
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Again, what distinguished NIFLA from Casey was the fact
that
Pennsylvania's speech-related mandate was aimed at
regulating the provision of medical treatments to patients;
the fact that the particular medical treatment at issue in
Casey involved a physical (instead of a verbal) act was of
no moment. NIFLA, 585 U. S., at 769–770. The reading of
NIFLA the United States favors—which the majority ap-
pears to endorse in part, see ante, at 649–650—is irrational
because, for purposes of the State's regulation of harmful
professional conduct, treatments administered through
words versus treatments administered through acts are not
meaningfully different.
5
By contrast, NIFLA's actual line marks a real, constitu-
tionally relevant distinction: Restrictions of speech that
occur when a State undertakes to regulate the treatments
that professionals provide to patients are merely “inciden-
tal”; they are materially different from speech restrictions
that are not “tied to a [medical] procedure at all.” 585 U. S.,
at 769–770; cf. Black's Law Dictionary 686 (5th ed. 1979) (de-
fning “incidental” as “[d]epending upon or appertaining to
something else as primary,” such as “something incidental to
the main purpose”). The latter warrants strict scrutiny
since the State is regulating “speech as speech,” while in the
former case—where the State is merely restricting speech
due to its regulation of medical treatments—heightened
scrutiny is not needed. 585 U. S., at 770.
The “speech incident to conduct” doctrine thus ably bal-
ances the interests at stake by accommodating a State's tra-
5
The majority appears to adopt a theory of the “speech incident to con-
duct” doctrine that is analytically similar to, but ultimately narrower than,
the recitation adopted by the United States. Ante, at 649–650. But, just
like the United States, the majority fails to account for NIFLA's conceptu-
alization of the doctrine as turning on the State's objectives. Indeed, the
majority's analysis offers no cohesive narrative to explain either why this
exception to heightened scrutiny exists or how—like all exceptions—it
operates to consistently effect a balance of the public's interests (here,
free speech and the personal safety that medical standards secure).

674 CHILES
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ditional police power to regulate the practice of medicine
for
the protection of its residents while also ensuring
that speech is not being targeted. As we explained in
NIFLA, that doctrine recognizes that the treatments pro-
vided by licensed medical professionals can be prohib-
ited even if, by doing so, the State incidentally restricts
those providers' speech. Id., at 769–770. This is constitu-
tionally permissible precisely because the restricted speech
is not being regulated “as speech”—i. e., based on or due
to its message or expressive content. Rather, the speech
restriction is a mere byproduct of the State's healthcare
regulation.
So, at the end of the day, I think what we have here is
what Casey involved and NIFLA did not: a State restricting
a medical provider's speech only as part of its regulation of
the provision of medical treatments to individual patients.
See NIFLA, 585 U. S., at 769–770; Casey, 505 U. S., at 884
( joint opinion of O'Connor, Kennedy, and Souter, JJ.). And
it is precisely because the MCTL is restricting Chiles's
speech “only as part of [her] practice of medicine” that the
First Amendment is not particularly bothered despite the
impact on her speech. Casey, 505 U. S., at 884 (same). Ac-
cordingly, talk therapists like Chiles—just like any other
healthcare provider seeking to treat patients—can presump-
tively be “subject[ed] to reasonable licensing and regulation
by the State.” Ibid.
B
The conclusion that a State can regulate the provision of
medical care even if, in so doing, it incidentally restricts the
speech of some providers, fully comports with the First
Amendment's animating principles. These principles in-
clude the well-settled notion that context matters when eval-
uating First Amendment challenges to state regulation.
See Virginia Bd. of Pharmacy, 425 U. S., at 762–768 (analyz-
ing the First Amendment protections due speech in the com-
mercial context); cf. Central Hudson Gas & Elec. Corp. v.
Public Serv. Comm'n of N. Y., 447 U. S. 557, 564, n. 6 (1980)
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Jackson, J., dissenting
(explaining how the context and characteristics of commer-
cia
l speech justify less scrutiny).
The context that frames today's debate is the kind of
speech that is at issue here—what I am calling (as short-
hand) “professional medical speech.” This is the only type
of speech the MCTL restricts.
1
Properly defned, “professional medical speech” is a nar-
row category. It is not all speech “uttered by `profession-
als.' ” NIFLA, 585 U. S., at 767. Rather, it is speech by
healthcare professionals made as part of their provision of
medical care to patients. To be even more specifc, profes-
sional medical speech occurs when a medical professional
speaks to a client (1) in the context of the professional-
patient relationship; (2) on matters within the provider's pro-
fessional expertise as defned by the medical community;
(3) for the purpose of providing medical care. See C. Haupt,
Professional Speech, 125 Yale L. J. 1238, 1247–1248 (2016); R.
Post, Informed Consent to Abortion: A First Amendment
Analysis of Compelled Physician Speech, 2007 U. Ill. L. Rev.
939, 947; D. Halberstam, Commercial Speech, Professional
Speech, and the Constitutional Status of Social Institutions,
147 U. Pa. L. Rev. 771, 834 (1999).
First, professional medical speech is speech uttered within
the bounds of the professional-patient relationship. See,
e. g., Haupt, 125 Yale L. J., at 1254–1255. That relationship
imposes certain duties and restrictions on the medical pro-
fessional. For example, medical providers are bound by the
twin duties of benefcence (the obligation to act for the bene-
ft of the patient) and nonmalefcence (the obligation not to
harm the patient). B. Varkey, Principles of Clinical Ethics
and Their Application to Practice, 2020 Med. Principles and
Prac. 17, 18.
6
6
This means, of course, that a provider is not employing professional
medical speech when speaking outside of the professional-patient relation-
ship. The provider who gives a speech touting the benefts of conversion
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Second, professional medical speech is speech within the
hea
lthcare provider's area of expertise as a member of the
medical community. Haupt, 125 Yale L. J., at 1248–1251.
Within the professional-patient relationship, the professional
has knowledge that the patient does not have, including
knowledge of which medical treatments are appropriate and
how to administer them. The patient comes to the provider
to access that expertise, which is informed by—and con-
strained by—what the medical community knows. See id.,
at 1243.
Finally, and most importantly, professional medical speech
is made for the purpose of providing the patient with medical
care. See id., at 1255. This speech is a tool employed to
treat patients. In this sense, professional medical speech fa-
cilitates the professional's goal of providing the patient with
the treatment, procedure, or healthcare that is within her
expertise and that forms the basis of the professional-
patient relationship.
2
Keeping in mind these characteristics of professional med-
ical speech, consider the First Amendment principles that
serve as guideposts for determining the level of scrutiny that
a government restriction of such speech deserves.
First, and most fundamentally, is preservation of the mar-
ketplace of ideas. See Abrams v. United States, 250 U. S.
616, 630 (1919) (Holmes, J., dissenting); Meyer v. Grant, 486
U. S. 414, 421 (1988). Indeed, the “whole project of the First
Amendment” stemmed from the Founders' desire to protect
the “critically important” goal of having “a well-functioning
sphere of expression, in which citizens have access to infor-
mation from many sources.” Moody v. NetChoice, LLC, 603
therapy, or writes a paper criticizing those who do not practice conversion
therapy, or even expresses to a patient her general (non-treatment-
related) views about conversion therapy does not have the duties that
arise in the context of the professional-patient relationship and, accord-
ingly, is not engaging in professional medical speech.
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U. S. 707, 732 (2024). Within the marketplace of ideas,
speech
that is expressive of the speaker's thoughts and views
is, generally speaking, highly valued. See Leathers v. Med-
lock, 499 U. S. 439, 447 (1991); Ashcroft v. American Civil
Liberties Union, 535 U. S. 564, 573–574 (2002).
But professional medical speech does not intersect with
the marketplace of ideas: “[I]n the context of medical prac-
tice we insist upon competence, not debate.” Post, 2007 U.
Ill. L. Rev., at 950. The degree to which medical providers
speaking within the boundaries of providing patient care can
express themselves is limited because their interactions with
patients are constrained by their well-established duties to
those patients and the requirement that they meet the stand-
ard of care. Moreover, given these limits, professional med-
ical speech does not necessarily involve the expression of
ideas or messages, so it does not provide signifcant value
to the general marketplace. See Dun & Bradstreet, Inc. v.
Greenmoss Builders, Inc., 472 U. S. 749, 758–759 (1985) (plu-
rality opinion).
That's not to say that there isn't a robust marketplace of
ideas within the medical community. Medical professionals
contribute to that particular marketplace by writing papers,
giving speeches, and pushing the bounds of the community's
knowledge through experimentation. And, indeed, the
standard of care for a medical treatment can be greatly in-
fuenced and changed by virtue of such speech. It is there
that truth competes for “accept[ance] in the . . . market.”
Abrams, 250 U. S., at 630 (Holmes, J., dissenting). But that
marketplace exists outside the confnes of the professional-
patient relationship. See Haupt, 125 Yale L. J., at 1243–1244
(discussi ng the epistemic marketplace among medica l
professionals).
Within the confnes of the professional-patient relation-
ship, treatment-related “truths” are a given—they are set
by licensing and malpractice standards, and it is not uncom-
mon that such regulation incidentally restricts provider
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speech. Moreover, regulation of the practice of medicine is
pe
rvasively and unavoidably viewpoint based. The major-
ity and the concurrence both resist this: They relentlessly
deride Colorado for engaging in “viewpoint discrimination”
by banning conversion therapy but permitting affrming
care. Ante, at 645–646 (majority opinion); ante, at 655–657
(Kagan, J., concurring). But context makes that point
ring hollow.
When a State establishes a standard of care, or punishes
a doctor for providing care outside of that standard, it neces-
sarily limits what medical professionals can say and do on
the basis of viewpoint. A State can permissibly “prohibi[t]
the administration of specifc drugs for particular medical
uses” but not for others. United States v. Skrmetti, 605
U. S. 495, 516 (2025).
7
So, too, may it prohibit a doctor from
encouraging a patient to commit suicide, see Tr. of Oral Arg.
43–45, or a dietician from telling an anorexic patient to eat
less, see id., at 22–23. Likewise, no one would bat an eye if
a State required its doctors to discourage, but not encourage,
smoking tobacco.
Even though these kinds of regulations are inherently
viewpoint based, in the context of medical care, a State can
certainly require the medical professionals it licenses to
stand on one side of an issue. See Collins v. Texas, 223 U. S.
288, 297–298 (1912) (recognizing the “right of the State to
adopt a policy even upon medical matters concerning which
there is difference of opinion and dispute”). Though these
proscriptions certainly promote a viewpoint, in this context,
that alone does not suffce to establish a presumptive First
Amendment violation. Instead, under the “speech incident
to conduct” doctrine, the challenged laws must also operate
7
Of course, when the State discriminates “on the basis of sex and trans-
gender status” with respect to the administration of specifc drugs, that
discrimination implicates the Equal Protection Clause and requires height-
ened scrutiny for purposes of the Fourteenth Amendment. See Skrmetti,
605 U. S., at 579 (Sotomayor, J., dissenting).

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as speech-suppression tools, designed to vanquish free
expressi
on.
But, here, Colorado's clear aim is enforcement of a stand-
ard of care that is indisputably applicable to the State's li-
censed healthcare professionals. Taking a position as to
how those providers should handle a medical issue is the
very essence of standard-setting—once again, this kind of
viewpoint-based regulation ensures “competence, not de-
bate.” Post, 2007 U. Ill. L. Rev., at 950. My colleagues'
contrary conclusions are puzzling, for a standards-based
healthcare scheme cannot function unless its regulators are
permitted to choose sides.
8
8
Faulting Colorado for legislating based on its view that conversion
therapy is harmful for minors and that affrming care is the better treat-
ment, the concurrence purports to save “for another day” the question
whether “content-based but viewpoint-neutral laws regulating speech in
doctors' and counselors' offces” comport with the First Amendment.
Ante, at 659 (opinion of Kagan, J.). But that magnanimity is a mirage.
Standards-based regulations exist in the medical context precisely because
the State has a view about safety or effcacy; regulation is a State's police-
power prerogative to promote those views (as the standard of care) while
simultaneously rejecting all others.
The laws I reference in Part IV, in fra, are not examples of content-
based, viewpoint-neutral laws, as the concurrence maintains. Contra,
ante, at 658, n. Rather, when properly analyzed, those laws are either
facially viewpoint based—see, e.g., the requirement that the medical pro-
fessional must not provide care “in a cruel manner,” Kan. Admin. Regs.
102–3–12a(b)(11) (2022)—or unavoidably viewpoint based in application.
Consider, for example, a therapist disciplined for failing to provide care that
promotes the “best interests” of her client. See Ga. Comp. Rules & Regs.,
Rule 135–7–.01(1) (2026). Punishment for a violation of that standard re-
quires the State to impose its view of what a therapist should have said
or done, and would necessarily “refect the [State's] disapproval” of the
speech the therapist actually employed. See Matal v. Tam, 582 U. S. 218,
249 (2017) (Kennedy, J., concurring in part and concurring in judgment).
But, of course, imposing the State's view of what is appropriate is the
entire point of standards-based regulation. The First Amendment allows
this because the State is regulating professional conduct and this profes-
sional's speech is only being incidentally restricted; the analysis does not
turn on whether the State's regulation is viewpoint neutral. Neutrality

680 CHILES
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A second and corollary First Amendment principle is the
l
istener's interest in receiving information. See Murthy v.
Missouri, 603 U. S. 43, 75 (2024); accord, Kleindienst v. Man-
del, 408 U. S. 753, 762 (1972). In the professional medical
context, however, informational asymmetry shapes the lis-
tener's interest. To be sure, “[r]espect for patients' auton-
omy is a cornerstone of medical ethics.” American Medical
Association Code of Medical Ethics, Opinion 11.2.4: Trans-
parency in Health Care (2026). But that interest is not
served by receiving all existing opinions—only information
about treatments that are within the standard of care ad-
vances patients' interests. Ibid. (“[P]hysicians have an obli-
gation to inform patients about all appropriate treatment
options” (emphasis added)). Patients are not in a position
to wade through medical discourse and independently evalu-
ate the best treatment for their circumstances. Their inter-
ests as listeners are thus limited by the nature and purpose
of the professional-patient relationship.
Third, and fnally, the First Amendment protects a speak-
er 's autonomy. “ ` [T]he fundamental ru le of protecti on
under the First Amendment [is] that a speaker has the au-
tonomy to choose the content of his own message.' ” Rums-
feld v. Forum for Academic and Institutional Rights, Inc.,
547 U. S. 47, 63–64 (2006) (quoting Hurley v. Irish-American
Gay, Lesbian and Bisexual Group of Boston, Inc., 515 U. S.
557, 573 (1995)). But, here again, with respect to profes-
sional medical speech, healthcare providers do not have au-
tonomy; when it comes to providing treatments for their pa-
tients, they are bound by the standard of care and are not
generally free to “choose the content” of their message. See
Haupt, 125 Yale L. J., at 1272; Halberstam, 147 U. Pa. L. Rev.,
at 867. Put differently, although medical professionals do
have an autonomy interest in communicating their ideas to
the patients they are treating, that interest only extends to
is not—and cannot be—the touchstone of the laws that govern the quality
of care that professionals provide to patients.
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treatment-related advice and information that is consistent
w
ith the standard of care.
In my view, the majority is mistaken to equate treatment-
related speech rendered in the context of providing medical
care with any spoken words uttered by any other speaker.
See, e. g., ante, at 644 (“While the First Amendment protects
many and varied forms of expression, the spoken word is per-
haps the quintessential form of protected speech. And that
is exactly the kind of expression in which Ms. Chiles seeks to
engage”). The majority is also wrong to insist that it is anti-
thetical to the First Amendment for a State to incidentally re-
strict a healthcare provider's treatment-related speech based
on a “prevailing standard of care” because “[m]edical consen-
sus . . . is not static; it evolves and always has.” Ante, at 654.
The mutability of medical standards tells us little about the
First Amendment's scope in a country where medical stand-
ards are enforceable by law and govern the treatment-related
conduct of professional healthcare providers.
Like it or not, treatment standards exist in America. And
those standards necessarily refect the expert medical com-
munity's current beliefs about the safety and effcacy of vari-
ous medical treatments, whatever those beliefs might be.
Medical standards are driven by science (objective facts and
data), but, naturally, they are not viewpoint neutral. Conse-
quently, the people win—not lose—when a State incorpo-
rates the medical profession's viewpoint into laws that re-
quire licensed treatment providers to conform to prevailing
standards of care. Contra, ante, at 655 (suggesting other-
wise). For this reason, the Court has long recognized a
State's power to regulate to protect its residents even in the
face of uncertainty. Cf. Gonzales v. Carhart, 550 U. S. 124,
163 (2007) (collecting cases and noting the “wide discretion”
afforded state legislatures to “pass legislation in areas where
there is medical and scientifc uncertainty”).
9
9
The majority laments that, because medical consensus is “not static,”
a law like the MCTL might operate to “silenc[e]” professional speech going
forward even if medical consensus swings the other way. Ante, at 654.
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Put differently, States impose treatment standards incor-
porati
ng the current consensus of medical experts to protect
state residents from harm. And they do this to ensure that
professionals provide patients with high-quality care. A
State that, alternatively, pursues an agenda of purposefully
silencing critics, muzzling opponents, or targeting views it
considers threatening would, of course, violate the First
Amendment. But it behooves us all (and especially courts)
to see and know the difference.
Ultimately, then, no traditional First Amendment princi-
ple justifes preventing a State from regulating medical care
simply and solely because its law happens to restrict
treatment-related speech. And in this case, there is zero
evidence that Colorado has engaged in the corrosive and il-
licit suppression of ideas that the First Amendment valiantly
repels. The record here does not show that Chiles is being
“target[ed]” or “muzzle[d]” or “silenced” or “censor[ed],” as
the majority suggests. Ante, at 646, 647, 653, 655. Instead,
as a healthcare provider licensed by the State of Colorado, she
is simply being held to the same standard of care that all other
licensed medical professionals in that State must follow.
10
Illustrating this problem, the majority points to shameful parts of this
country's past to show the dangers that can come from regulation that
relies on outdated medical practices. Ibid. (citing Buck v. Bell, 274 U. S.
200, 205–207 (1927)). But the majority does not mention that, if the
standard of care does change, the state legislature has the power to change
the law in response to that evidence. The majority's point seems to be
that States should not be permitted to enact (rigid) laws based on current
scientifc thought because expert opinions might shift over time. But
those uncertainties—which have always existed—are no reason to aban-
don medical standards or to alter how the law has traditionally accommo-
dated scientifc discoveries. The potential that medical consensus may
change in the future does not mean that the Constitution prevents a State
from acting today to protect its residents from what medical experts cur-
rently believe is a harmful medical treatment.
10
Under my analysis, evidence of speech targeting or suppression could
include the fact that the challenged state regulation does not, in fact, refect
current medical consensus. See ante, at 654–655 (noting the mutability of
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Jackson, J., dissenting
The MCTL's conversion-therapy ban only incidentally re-
str
icts professional medical speech as a result of Colorado's
regulation of a harmful medical treatment; nothing compels
the conclusion that a state regulation that operates to re-
strict this kind of communication in this way is targeting
speech qua speech.
III
The centuries-long tradition of States using their police
powers to establish and enforce the standards of care that
bind medical professionals—including those who use speech
to administer treatments—is another indication that height-
ened scrutiny does not and need not apply here. The major-
ity's opinion largely omits this broader historical record.
But, when consulted, that history demonstrates unequivo-
cally that the MCTL is neither unusual nor inherently
suspect.
States have always had “broad power to establish stand-
ards for licensing practitioners and regulating the practice
of professions.” Goldfarb v. Virginia State Bar, 421 U. S.
773, 792 (1975). With respect to the medical profession in
particular, States have used that power to control how medi-
cine is practiced “from time immemorial.” Dent v. West Vir-
ginia, 129 U. S. 114, 122 (1889).
the medical consensus). If a State enacts a treatment prohibition that
substantially diverges from the medical community's present beliefs, the
law might well be a pretext for illicit speech-targeting objectives. Far
from requiring “refexive deference,” id., at 654, proof of such motivation
would be unearthed, and carefully examined, as part and parcel of a court's
proper “speech incident to conduct” inquiry, since the doctrine is only ap-
plicable to reasonable State regulations. See Planned Parenthood of
Southeastern Pa. v. Casey, 505 U. S. 833, 884 (1992) ( joint opinion of O'Con-
nor, Kennedy, and Souter, JJ.) (noting that medical professionals are “sub-
ject to reasonable licensing and regulation by the State”); NIFLA, 585
U. S., at 785 (Breyer, J., dissenting) (stating that the First Amendment
y ields to “reasonable conditi ons” that St ates i mpose on medica l
providers).
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States have historically regulated the medical profession
i
n two complementary ways: licensing schemes and medical-
malpractice liability. Both necessarily encompass restric-
tions on professional medical speech through the regulation
of the provision of medical care.
Medical licensing began as early as 1639, before this coun-
try was founded. R. Horowitz, In the Public Interest: Medi-
cal Licensing and the Disciplinary Process 39 (2013). Many
States deregulated in the mid-1800s by abolishing their li-
censing schemes. Id., at 40. But regulation through licens-
ing was not abandoned for long: By the turn of the 20th cen-
tury, 12 States had adopted licensing laws. D. Johnson & H.
Chaudhry, Medical Licensing and Discipline in America: A
History of the Federation of State Medical Boards 23 (2012).
We held that such laws were a permissible exercise of a
State's traditional police powers, declaring that “[t]he power
of the state to provide for the general welfare of its people
authorizes it to prescribe all such regulations as, in its judg-
ment, will secure or tend to secure them against the conse-
quences of ignorance and incapacity as well as of deception
and fraud.” Dent, 129 U. S., at 122; see also Watson v.
Maryland, 218 U. S. 173, 176 (1910) (rejecting challenge to
medical-licensing law).
Today, every State has a medical-licensing scheme. See
App. to Brief for Health Law Scholars as Amici Curiae. In
practice, medical licensing serves two functions, both essen-
tial to patient safety. First, as the majority emphasizes, li-
censing sets limits on who may practice medicine. See
P. Larkin, M. Fishpaw, & L. McCarthy, Telemedicine and Oc-
cupational Licensing, 73 Admin. L. Rev. 747, 774 (2021); ante,
at 652. But the second function is more important for this
case: State licensing laws also regulate how those profession-
als may practice, by requiring them to adhere to a standard
of care. See Brief for Respondents 27; see also App. to id.,
at 1a–8a (listing state laws that require medical and mental

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Jackson, J., dissenting
health professionals to be licensed and to comply with profes-
si
onal standards).
While licensing regulates medical professionals ex ante,
medica l-ma lprac tice lawsuits enforce those st andards
ex post. And just like medical licensing, the tort of medical
malpractice has a long pedigree.
English common law held doctors liable for harm caused
by their negligent medical treatment. 3 W. Blackstone,
Commentaries on the Laws of England *122 (W. Lewis ed.
1922) (1768). The English tradition carried forward; this
legal claim has been available in our country since the found-
ing. See K. De Ville, Medical Malpractice in Nineteenth-
Century America: Origins and Legacy 3, 5 (1990) (De Ville).
In the mid-1800s, the number of malpractice cases skyrock-
eted, flling the void left by the States' temporary deregula-
tion of medical licensing. See id., at 25–34; see also id.,
at 115–137; Graham v. Gautier, 21 Tex. 111, 117–118 (1858)
(observing that the lack of a licensing scheme demanded
enforcement of a corresponding standard of care).
Historically, the medical-malpractice tort generally re-
quired the plaintiff to prove three things: (1) that there was
a professional-patient relationship, (2) that the medical pro-
fessional had caused him harm, and (3) that the provider had
departed from a standard of care. De Ville 46–50. The ma-
jority focuses on the requirement to show harm. Ante, at
653–654. But the entire point of the third element was to
reinforce the standards that govern medical practitioners.
For that reason, the harmed plaintiff was required to establish
that the accused physician had not practiced with “ordinary
care, diligence, and skill.” See De Ville 49 (emphasis deleted).
State enforcement of the standard of care—i. e., “the care,
skill, and knowledge regarded as competent among similar
medical providers in the same or similar circumstances,” Re-
statement (Third) of Torts: Medical Malpractice § 5 (Tent.
Draft No. 2, Mar. 2024)—has continued over time and still
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serves as the touchstone for both licensing schemes and
medica
l-malpractice lawsuits. Brief for Respondents 25–26,
and App. to id., at 1a–8a. That is, States have consistently re-
gulated medical professionals' conduct to ensure that modern
healthcare practices conform to the standard of care through
both medical-malpractice law and professional licensing.
Note, too, that such state regulation has not been limited
to medical procedures: Physicians have historically been held
liable for what they said when administering those proce-
dures as well. See Graham, 21 Tex., at 119–120 (imposing
liability for medical advice); Edwards v. Lamb, 69 N. H. 599,
45 A. 480 (1899); Skillings v. Allen, 143 Minn. 323, 173 N. W.
663 (1919). Moreover, in the past, States have—as part of
their licensing regulations—defned the “practice of medi-
cine” to cover practitioner speech. See, e. g., Smith v. Peo-
ple, 51 Colo. 270, 272, 117 P. 612, 613 (1911) (noting that the
“practice of medicine” as regulated by Colorado's licensing
law included “suggestion[s or] recommendation[s] . . . of
treatment”).
In short, States have regulated professional conduct re-
lated to the provision of all kinds of medical care—and inci-
dentally restricted speech—without constitutional affront
for eons. Though the majority averts its gaze, even a cur-
sory glance at the broader historical record is illuminating,
for it reveals that States have traditionally played a signif-
cant role in setting the standards that govern the medical
profession. See Washington v. Glucksberg, 521 U. S. 702,
731 (1997) (emphasizing the state interest “in protecting the
integrity and ethics of the medical profession”); Barsky v.
Board of Regents of Univ. of N. Y., 347 U. S. 442, 451 (1954)
(same).
With the MCTL, Colorado has merely taken up that same
mantle. That law operates by prohibiting a particular medi-
cal treatment the State considers harmful, and nothing about
it implicates Chiles's First Amendment rights in a markedly
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Jackson, J., dissenting
different fashion than other States' traditional efforts to reg-
u
late and enforce the standard of care.
11
One more thought on this: The majority rigidly imposes a
history-and-tradition test that treats the plethora of histori-
cal examples as insuffcient. See ante, at 650–654. But it
should instead fnd the long tradition of state laws setting
standards of care by regulating the professional conduct of
medical providers—including those who treat with speech—
doubly reassuring.
For one thing, this history helps us to be confdent that
what Colorado is doing here is actually regulating medical
care, not suppressing messages. The record shows that
States have routinely enacted laws that establish and enforce
the standard of care, and that serves as a backdrop for an
understanding of how States have acted historically to pro-
tect their residents from harm. The majority is right about
one thing, however: A State will always say that its law just
regulates the provision of medical treatments, while the
challenger will inevitably argue that the State's law nefari-
ously targets speech qua speech. See ante, at 648. A
lengthy tradition of similar regulatory efforts by States—or
the absence of one—helps courts to ferret out who has the
better of that argument.
The history also helpfully demonstrates that a lower level
of scrutiny is appropriate here, despite the impact of the
MCTL on Chiles's speech. We can rest easy, comforted by
the fact that this law is not actually operating to suppress
the expression of thoughts, messages, or ideas about conver-
11
The majority's observation that “counselor-licensure bill[s]” are a rela-
tively recent innovation, ante, at 652, is an interesting diversion. But
that is all. The relevant historical question is whether States have histor-
ically regulated the medical care that licensed professionals provide to
patients, including treatments that are delivered via speech. The answer
is yes; the fact that counselors have only recently been included in the
regulated category of “licensed medical professionals” is beside the point.
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sion therapy; instead, the MCTL restricts talk therapists in
the
same way and to the same extent as other healthcare
professionals have historically been limited when treating
patients. Like other valid licensing restrictions, the MCTL
does not prevent Chiles from speaking out in favor of conver-
sion therapy, promoting conversion therapy, or otherwise
lending credence to efforts to validate that therapy. All this
law does is prohibit Chiles from providing this treatment to
minor patients—no different than what Colorado and other
States have been doing in the indisputably valid exercise of
their police powers for centuries.
12
12
Suggesting otherwise, the majority places great stock in our decision
in Holder v. Humanitarian Law Project, 561 U. S. 1 (2010). See ante, at
642, 648–649. Holder involved a law that prevented lawyers and doctors
from providing “ `material support' ” for others' terrorist activities by
word or deed. 561 U. S., at 8–9. We subjected the law to strict scrutiny
because, as applied to the plaintiffs, the law was aimed at preventing pro-
fessionals from “communicating a message.” Id., at 28. Such a regula-
tion plainly raised the specter of suppression—i. e., that what the United
States was really aiming to do was prevent those professionals from ex-
pressing support for something the United States found distasteful. In
other words, the challenged law sought to punish the plaintiffs based on
the expressive content of their speech. That is not what we have here.
The MCTL—which follows in a long line of state regulation of healthcare
providers' treatment-related conduct—does not restrict or punish medical
professionals because of the expressive content of their communications.
Rather, the speech restriction happens only incidentally; the MCTL's in-
disputable objective is prohibiting a harmful medical treatment. To put
a fner point on this: The equivalent of Chiles's First Amendment claim,
transported to the Holder context, would be as if the United States in
Holder had said: “you professionals are prohibited from committing acts
of terrorism,” and the lawyers among them responded, “it is unconstitu-
tional to apply your `no terrorist acts' prohibition to us because we want
to commit the prohibited terrorist acts with our speech.” But, of course,
the First Amendment would not prevent the United States from prohibit-
ing all terrorist acts even if, by doing so, it incidentally restricts the
speech that some actors might otherwise have used to behave in the man-
ner the law prohibits. In my view, that is how Chiles's constitutional
claim works (and also why it fails).

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All things considered, then, I reach a different conclusion
i
n this case than the majority does because precedent, princi-
ples, and history point in the same direction: No heightened
scrutiny is warranted here. The First Amendment cares
about government efforts to suppress “speech as speech”
(based on its expressive content), not laws that, like the
MCTL, restrict speech “incidentally,” due to the govern-
ment's traditional, garden-variety regulation of such speak-
ers' professional conduct.
IV
Ultimately, because the majority plays with fre in this
case, I fear that the people of this country will get burned.
Before now, licensed medical professionals had to adhere to
standards when treating patients: They could neither do nor
say whatever they want. Largely due to such State regula-
tion, Americans have been privileged to enjoy a long and
successful tradition of high-quality medical care.
Today, the Court turns its back on that tradition. And, to
be completely frank, no one knows what will happen now.
This decision might make speech-only therapies and other
medical treatments involving practitioner speech effectively
unregulatable—not to be reached via licensing standards,
medical-malpractice liability, or any other means of state
control. Who knows? Certainly not the majority. It
appears to have made this momentous decision without
adequately grappling with the potential long-term and
disastrous implications of this ruling.
The fallout could be catastrophic. Many regulations im-
pact the speech of medical professionals in the context of
their provision of healthcare to patients; the possibilities go
far beyond talk therapy and informed consent. For exam-
ple, many States require that medical professionals “make
every reasonable effort to promote the welfare, autonomy
and best interests of ” the client. Ga. Comp. Rules & Regs.,
Rule 135–7–.01(1) (2026); see Ind. Admin. Code, tit. 839, § 1–
§ 5–5(1) (2026); Conn. Gen. Stat. § 17a–542 (requiring “[h]u-
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mane and dignifed treatment”) (2025); Ala. Admin. Code
Ru
le 255–X–11–.01 (Supp. 2016) (requiring that the profes-
sional “assure client welfare and protection” during medical
care). Some States further prohibit medical professionals
from treating a patient “in a cruel manner.” Kan. Admin.
Regs. 102–3–12a(b)(11) (2022). Similarly, some licensing
boards can discipline a provider who “is incompetent.”
Alaska Stat. § 08.29.400(4) (2025).
13
On the majority's view, these kinds of regulations become
unenforceable if the healthcare provider risks harming pa-
tients with their speech rather than an operation. Provid-
ers who offer “cruel” speech-only therapies or who use
speech to (intentionally or incompetently) harm the welfare
of patients, for example, can now assert a First Amendment
right to carry on, regardless of these standards.
So, to put it bluntly, the Court could be ushering in an era
of unprofessional and unsafe medical care administered by
effectively unsupervised healthcare providers. A state li-
cense used to mean something to the patients who entrust
their care to licensed professionals—i. e., that the person is
certifed to be one who provides treatments that are consist-
ent with the standard of care.
That stops today. Indeed, it is not at all clear how, or
to what extent, state regulation of medical care involving
practitioner speech can survive this holding. We are on a
slippery slope now: For the frst time, the Supreme Court
has interpreted the First Amendment to bless a risk of ther-
apeutic harm to children by limiting the State's ability to
13
Those are not the only restrictions that constrain the speech of medi-
cal professionals. Some States require that a counselor make a treatment
plan specifying goals and methods, and ensure that such plan is “viab[ le]
and effectiv[e].” Ariz. Admin. Code, Rule R4–6–1102 (Sept. 2025). Oth-
ers prohibit “making claims of professional superiority that one cannot
substantiate” or “guaranteeing that satisfaction or a cure will result from
the performance of professional services.” Kan. Admin. Regs. 102–3–
12a(b)(31), (32). Still others prohibit the professional from “exercis[ing]
undue infuence on the client.” Colo. Rev. Stat. § 12–245–224( j).
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regulate medical providers who treat patients with speech.
W
hat's next? In the worst-case scenario, our medical sys-
tem unravels as various licensed healthcare professionals—
talk therapists, psychiatrists, and presumably anyone else
who claims to utilize speech when administering treatments
to patients—start broadly wielding their newfound constitu-
tional right to provide substandard medical care.
It is baffing that we could now be standing on the edge of
a precipitous drop in the quality of healthcare services in
America. But the Court sees ft to bring us one step closer
to that fate today. Stranger still is the fact that this possi-
bility looms in the 21st century—given what science now en-
ables us to know about medical conditions and treatments,
what our cases say, and what we all should have learned by
now from history. Somehow, Justices from eras past have
always understood that (as I stated at the outset) “there is
no right to practice medicine which is not subordinate to the
police power of the States.” Lambert, 272 U. S., at 596.
They correctly applied that simple but powerful understand-
ing of our Constitution across the board—to all healthcare
professionals, including those with practices that happen to
involve treatment-related speech. We do harm to both the
Nation's medical system and our First Amendment jurispru-
dence by ignoring that wisdom today.
***
The First Amendment requires heightened scrutiny when
States regulate “speech as speech” but not when speech is
restricted “incidentally.” NIFLA, 585 U. S., at 769–770.
The latter occurs where, as here, a State seeks to prohibit
healthcare professionals from providing a dangerous medical
treatment in all of its forms, including the speech-related
variety. States have traditionally regulated the provision
of medical care through licensing schemes and malpractice
regimes without constitutional incident. And no core prin-
ciple of our First Amendment jurisprudence leads inexorably
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to the conclusion that it violates the Constitution for a State
to
prevent its licensed talk therapists from using speech to
harm the minors in their care. Holding otherwise, as the
majority does now, fouts centuries of state-standardized reg-
ulation of medical care and is, ultimately, nonsensical. The
Constitution does not pose a barrier to reasonable regulation
of harmful medical treatments just because substandard care
comes via speech instead of scalpel.
Accordingly, I cannot agree with the majority's analysis or
its conclusions in this case. The majority fnds, at bottom,
that Colorado likely cannot legislate to protect the children
of its State if, by doing so, it happens to keep state-licensed
healthcare providers from saying what they want to say to
minors. And the majority's holding means, in effect, that
just because Chiles is a talk therapist—and not, say, a sur-
geon—a State can be prevented from incidentally imposing
reasonable restrictions on the treatments she provides. Our
precedents do not compel this conclusion. In fact, NIFLA
draws a different line, and the correct course of action here is
to hold it: Speech uttered for purposes of providing medical
treatment may be restricted incidentally when the State rea-
sonably regulates the speaker's provision of medical treat-
ments to patients. Id., at 769–770.
To do anything else opens a dangerous can of worms. It
threatens to impair States' ability to regulate the provision
of medical care in any respect. It extends the Constitution
into uncharted territory in an utterly irrational fashion.
And it ultimately risks grave harm to Americans' health
and wellbeing.
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Reporter’s Note
The attached opinion has been revised to refect the usual publication
and citation style of the United States Reports. The revised pagination
makes available the offcial United States Reports citation in advance of
publication. The syllabus has been prepared by the Reporter of Decisions
for the convenience of the reader and constitutes no part of the opinion of
the Court. A list of counsel who argued or fled briefs in this case, and
who were members of the bar of this Court at the time this case was
argued, has been inserted following the syllabus. Other revisions may
include adjustments to formatting, captions, citation form, and any errant
punctuation. The following additional edits were made:
p. 673, line 9: “of ” is inserted after “purposes”
p. 681, line 9 from bottom: “the” is inserted after “incorporates”